^^;^" 


RD34  So1 


HX64062309ern— clmic 


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Columbia  SJmbersittp 
intljeCttpofJIetogork 

COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


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Orcian ;  nlt-rect  C- 

International  Clinic  Week 


AT    THE 


New  York  Polyclinic  Medical 
School   and   Hospital 


DURING    THE 


International  Surgical  Congress 
April,  1914 


fa~**~*     Y    "^**"^* 


New  York 


'''Jlijwfei.'.   I'l ■■'.,  .-   'IF 


International  Clinic  Week 


AT    THE 


New  York  Polyclinic  Medical 
School   and    Hospital 


DURING    THE 


International  Surgical  Congress 
April,  1914 


ALFRED  C.  JORDAN,  M.D. 

EUGENE  HERTOGHE,  M.D. 

BENJAMIN  MERRILL  RICKETTS,  M.D. 

JOHN  A.  WYETH,  M.D. 

JOHN  A.  BODINE,  M.D. 

ALEXANDER  LYLE,  M.D. 

WILLIAM  SEAMAN  BAINBRIDGE,  M.D. 


New  York 


INDEX 


PAGE 

INTRODUCTION  ------        5 

Tuesday,  April  14 

"CHRONIC  INTESTINAL  STASIS —INTERNAL 
PHOTOGRAPHY  AS  AN  AID  TO  DIAG- 
NOSIS, ILLUSTRATED."  -•      -        -        7 

ALFRED  C.  JORDAN,  M.D.,  Cantab,  M.R.C.P.,  Med- 
ical Radiographer,  Guy's  Hospital,  and  Royal  Hospital 
for  Diseases  of  the  Chest,  London. 

Wednesday,  April  ij 

"THYROID  DEFICIENCY,"  LECTURE  AND 
DEMONSTRATION,  WITH  STEREOPTI- 
CON  PICTURES." 29 

Dr.  EUGENE  HERTOGHE,  Member  of  the  Royal 
Academy  of  Medicine,  Belgium. 


Thursday,  April  16 
''INTRATRACHEAL   INSUFFLATION."      -        -       78 

BENJAMIN     MERRILL    RICKETTS,    M.D.,    LL.D., 
Cincinnati,  Ohio. 


Friday,  April  17 

FOUR  CLINICAL  LECTURES,  PROFESSORS  OF 
SURGERY,  NEW  YORK  POLYCLINIC 
MEDICAL  SCHOOL  AND  HOSPITAL: 

I  "FRACTURES  AND  BURNS."        -        -      89 

JOHN  A.  WYETH,  M.D.,  LL.D. 

II  "OPERATIONS  FOR  INGUINAL  HER- 

NIA UNDER  LOCAL  ANESTHESIA."      93 
JOHN  BODINE,  M.D. 

III  "FRACTURES."      -----      95 

ALEXANDER  LYLE,  M.D. 

IV  "CANCER." 100 

WILLIAM    SEAMAN    BAINBRIDGE,    Sc.D., 
M.D.,  CM. 


INTRODUCTORY  NOTE. 

In  an  editorial  entitled,  "A  Notable  Surgical 
Clinic,"  Dr.  Thomas  L.  Stedman,  editor  of  the 
Medical  Record,  said  in  part :  "In  the  issues  of 
the  Medical  Record  for  September  19  and  26  a 
large  amount  of  space  available  for  original 
communications  has  been  given  to  papers  read 
and  reports  of  clinics  held  at  the  New  York 
Polyclinic  during  the  week  of  the  International 
Surgical  Congress  which  met  in  this  city  last 
spring.  In  honor  of  this  Congress  the  Faculty 
of  the  Polyclinic  requested  the  surgical  staff  of 
the  institution  to  open  its  doors  to  the  visiting 
members  of  the  profession,  and  to  arrange  a 
series  of  lectures  and  clinics.  Accordingly,  on 
four  days  of  that  week  the  surgical  lectures  and 
demonstrations  were  given  which  have  here 
been  reproduced  for  the  benefit  of  our  readers. 

"This  was  the  first  occasion  on  which  the  In- 
ternational Surgical  Congress  had  met  in  this 
country — in  fact  the  first  time  it  had  been  held 
elsewhere  than  in  Brussels,  the  city  of  its  birth. 
One  can  but  wonder  where  the  next  Congress 
will  meet  and  when — when  indeed  the  enmities 
and  hatreds  engendered  by  this  European  strife 
will  have  become  so  far  dulled  that  any  really 
international  meeting  will  be  possible,  even  of 
medical  men.  These  are  wont  to  boast  in  their 
gatherings,  in  the  intervals  of  war,  that  science 
is  truly  international,  untinged  by  jealousies  of 
race  and  nation,  but  when  war  comes  they  find 
that  after  all  blood  is  thicker  than  water  and 
love  of  country  is  more  compelling  than  love  of 
science." 

When  the  Surgical  Staff  of  the  New  York 
Polyclinic  Medical  School  and  Hospital  arranged 
for  the  "International  Clinic  Week,"  in  honor 
of  the  members  and  friends  of  the  International 
Surgical  Congress,  they  had  no  thought  that 
perhaps  the  Empire  City  of  the  Western  World 
might  witness  the  unforeseen  ringing  down  of 
the  curtain  for  a  time  upon  the  corporate  life 
of  this  body  of  distinguished  surgeons  who,  in- 


dividually  and  collectively,  have  accomplished 
such  splendid  work  for  science  and  for 
humanity. 

This,  however,  may  be  the  case, — not,  per- 
haps, because  "the  love  of  country  is  more  com- 
pelling than  the  love  of  science,"  but  because 
of  the  years  of  reconstruction,  of  privation,  and 
of  general  disheartenment  that  must  of  neces- 
sity follow  the  unfortunate  struggle  which  now 
engulfs  the  major  part  of  the  world,  and  which, 
in  truth,  affects  deeply  the  whole  world. 

For  all  these  reasons  we  are  glad  to  respond 
to  repeated  requests  for  the  perpetuation,  in 
convenient  form,  for  those  who  attended  the 
International  Surgical  Congress  and  the  Inter- 
national Clinics  held  at  the  Polyclinic,  the  lec- 
tures and  clinics  held  on  that  occasion. 

We  venture,  however,  to  express  the  hope  and 
the  belief  that  when  the  present  conflict  of  na- 
tions shall  have  ended  the  medical  world  will 
find  itself  once  more  united  in  the  earnest  effort 
to  alleviate  human  suffering  and  to  render  more 
and  more  impossible,  through  the  development 
of  a  higher  brotherhood,  a  repetition  of  the 
tragedies  now  being  enacted. 


CHRONIC  INTESTINAL  STASIS. 

By  ALFRED   C.   JORDAN,   M.D.,   CAMB.,   M.R.C.P., 


I  HAVE  the  honor  to  address  you  on  one  of  the  most 
fascinating  and  far-reaching  branches  of  medical 
study;  a  vast  realm  that  has  been  opened  up  by  the 
genius  and  insight  of  our  great  surgeon,  Sir. 
Arbuthnot  Lane. 

Intestinal  stasis  is  a  chronic  disease  due  to  the 
absorption  of  poisonous  substances  from  the  ali- 
mentary canal.  The  disease  itself  may  be  so  in- 
sidious as  to  escape  notice,  while  a  complication  may 
produce  severe  and  urgent  symptoms,  and  compel 
instant  attention.  In  this  way  we  have  hitherto 
lost  sight  of  the  fundamental  disease— the  stasis — 
and  we  have  fixed  our  attention  on  the  complica- 
tion, regarding  this  as  a  primary  disease. 

The  general  signs  and  symptoms  of  intestinal 
stasis  are  too  well  known  to  require  a  detailed 
description.  A  full  and  most  graphic  account  is 
contained  in  Sir  Arbuthnot  Lane's  recent  paper 
{Practitioner,  March,  1914) . 

I  am  concerned  with  the  radiological  demonstra- 
tion of  the  changes  found  in  cases  of  intestinal 
stasis.  When  first  I  took  up  this  work  I  was  handi- 
capped by  the  belief  that  the  patient  must  be  "pre- 
pared" for  the  bismuth  meal  by  giving  him  purges 
and  enemata,  and  that  he  must  take  his  bismuth 
in  the  form  of  a  "meal"  while  fasting.  Many  radi- 
ologists adhere  to  this  mode  of  preparation  still, 
but  I  am  perfectly  sure  that  once  they  have  made 
up  their  minds  to  abandon  it  they  will  never  return 
to  it. 

The  best  way  to  give  the  bismuth  is  in  the  form 
of  an  emulsion  to  be  taken  about  an  hour  after  an 
ordinary  breakfast.  The  reasons  for  this  were  given 
fully  by  me  in  a  recent  paper   {Brit.  Med.  Jour., 

Copyright,  William  Wood  &  Company. 


November  22,  1913).  In  the  vertical  posture  the 
emulsion  is  seen  to  pass  through  the  esophagus 
rapidly,  and  to  fall  at  once  to  the  great  curvature 
of  the  stomach.  The  patient  then  lies  on  the  couch 
on  his  right  side  to  allow  the  bismuth  to  fill  the 
pylorus  and  duodenum.  After  a  minute  or  so  he 
lies  on  his  back,  and  is  examined  with  the  fluorescent 


Fig.  1. — Simple  ileal  stasis,  taken  on  the  couch  37  hours 
after  a  bismuth  meal  in  a  woman  aged  40  suffering  from 
advanced   cystic   disease   of   the   breasts. 


screen.  In  the  normal  case  the  duodenum  is  small 
and  short,  its  vertical  portion  measuring  23/4-3l/4 
inches;  in  a  few  seconds  a  duodenal  peristaltic  wave 
starts  near  the  top  of  the  duodenum,  and  carries 
before  it  the  whole  contents  of  the  duodenum  with- 
out delay  through  its  four  parts  and  on  to  the 
jejunum.  At  the  end  of  three  or  four  hours  there 
is  no  longer  any  bismuth  in  the  stomach  or  duo- 
denum; the  whole  of  it  is  in  the  lower  abdomen, 
partly  in  the  lower  coils  of  the  ileum,  partly  in  the 
cecum  and  ascending  colon.  In  perfectly  normal 
cases  the  lower  ileal  c.oils  lie  above  the  pelvic  brim, 
and  there  is  never  a  very  large  collection  of  bismuth 
in  these  coils,  the  passage  through  the  ileocecal 
valve  being  free.  One  of  the  very  earliest  effects 
of  stasis  is  to  cause  the  lower  ileal  coils  to  drop 
into  the  pelvis.  There  is  then  a  long  rise  from  the 
pelvis  to  the  cecum.  Spasm  of  the  ileocecal  valve 
occurs,  and  adds  to  the  difficulty.     The  last  inches 


Fig.  2. — Great  stasis  in  the  large  intestine,  with  elongation 
of  the  pelvic  colon,  taken  on  the  couch  80  hours  after  a  bis- 
muth meal  in  a  woman  aged  46  suffering  from  advanced 
cystic  disease  of  the  breasts.  There  was  also  extreme  ileal 
stasis,  and  the  patient  showed  all  the  usual  signs  and  symp- 
toms of  chronic  intestinal  stasis. 


of  the  ileum  become  hypertrophied  to  a  thick  cord 
which  is  easily  felt.  In  many  cases  the  weight  of 
the  overloaded  cecum  and  ileum  causes  a  constant 
pull  on  the  mesentery  of  the  ileum  whenever  the 
patient  is  upright ;  a  thickening  then  appears  in  the 
mesentery  at  the  point  where  the  pull  is  greatest. 
The  point  of  greatest  strain  varies  from  case  to 
case;  often  it  is  within  an  inch  of  the  ileocecal 
valve  (Fig.  14)  ;  sometimes  it  is  in  the  right  iliac 
fossa  about  four  inches  from  the  valve  (Figs.  4,  5, 
and  19)  ;  in  other  cases  again  it  is  just  above,  or 
just  below  the  pelvic  brim. 

It  is  clear,  then,  that  the  ileal  kink  is  not  the 
primary  cause  of  the  ileal  stasis,  although  the  kink, 
when  present,  aggravates  the  stasis,  at  any  rate  in 
the  upright  posture.    I  find  there  is  still  much  mis- 


understanding  on  this  point.  It  is  the  ileal  stasis 
which  produces  the  kink,  by  pulling  on  the  mesen- 
tery of  the  ileum.  Some  of  the  worst  cases  of 
ileal  stagnation  occur  in  feeble  women,  and  in  them 
a  kink  may  never  appear  (Fig.  1).  In  such  cases 
there  is  often  extreme  dropping  of  the  large  intes- 
tine, the  cecum  occupying  the  deepest  part  of  the 
pelvis.  The  ileal  contents  have  not  then  to  negotiate 
a  rise  to  the  cecum ;  the  difficulty  must  be  enhance* 
by  the  ileocecal  valve,  which  gets  into  a  state  of 
spasm  seldom  fully  relaxed. 


Fig.  3. — Taken  on  the  couch  after  a  bismuth  meal  in  a 
woman  aged  47,  showing  the  duodenum  and  the  plyoric  por- 
tion of  the  stomach.  The  woman  suffered  from  severe  glyco- 
suria ;  at  the  age  of  30  she  had  exophthalmic  goiter  for  six 
months.  The  screen  showed  active  gastric  peristalsis  with 
plyoric  spasm.  The  duodenum  was  dilated,  and  showed 
strong  "writhing"  peristalsis  with  repeated  return  of  the  bis- 
muth from  the  third  to  the  second  part  of  the  duodenum,  only 
traces  of  bismuth  having  entered  the  jejunum  at  the  end  of 
15  minutes.  C,  P,  cardiac  and  pyloric  portions  of  the  stom- 
ach ;  Py.,  pylorus  a,  b,  c,  d,  the  four  parts  of  the  duodenum  ; 
U,  the  umbilicus.    (See  also  Figs.  4,  5,  and  6.) 

With  regard  to  the  large  intestine  I  propose  to 
say  little,  except  incidentally  to  explain  its  effect 
on  other  parts.  In  normal  cases  the  bismuth  begins 
to  enter  the  cecum  in  three  to  four  hours ;  in  six  to 
eight  hours  it  has  reached  the  middle  of  the  trans- 
verse colon ;  in  eight  to  ten  hours  the  splenic  flexure, 
and  in  eighteen  to  twenty-four  hours  the  rectum. 
At  this  stage  (twenty-four  hours)  there  is  usually 
bismuth  in  all  parts  of  the  large  intestine,  fairly 
evenly  distributed.  At  the  end  of  forty-eight  hours 
all  the  bismuth  should  have  been  evacuated.  The 
delay  in  the  large  intestine  in  stasis  is  often  ex- 
treme, and  after  one  hundred  hours  there  may  be 


10 


little  bismuth  beyond  the  splenic  flexure.  Un- 
doubtedly a  good  deal  of  toxic  absorption  occurs 
from  the  stagnant  contents  of  the  large  intestine, 


Fig.  4. — Taken  on  the  couch  9  hours  after  the  same  bismuth 
meal.  There  was  still  a  large  amount  of  bismuth  in  the 
stomach — kept  back  by  the  pyloric  spasm.  The  terminal  coil 
of  the  ileum  was  tortuous  and  thick-walled ;  it  was  firmly 
fixed  in  the  right  iliac  fossa  (Lane's  kink).  The  appendix, 
seen  beneath  the  cecum,  was  freely  movable,  and  appeared 
healthy. 


Fig.  5. — Taken  23  hours  after  the  same  bismuth  meal, 
showing  the  ileal  kink  as  before  with  extreme  ileal  stasis,  the 
lower  ileal  coils  being  still  well  filled  with  bismuth. 


11 


Fig.  6. — Taken  on  the  couch  47  hours  after  the  same  bis- 
muth meal  ;  i.e.  at  a  time  when  all  the  bismuth  would  have 
been  evacuated  in  a  normal  case  ;  the  transverse  colon  dips 
vertically  into  the  deepest  part  of  the  pelvis,  and  no  bismuth 
has  advanced  beyond  the  middle  of  the  transverse  colon. 
After  95  hours  no  bismuth  had  been  passed,  and  very  little 
had  got  beyond  the  transverse  colon.  A  few  days  later  dia- 
betic coma  supervened,  and  the  patient  died. 

but  the  greatest  harm  arises  from  the  damming 
back  of  the  contents  of  the  ileum,  these  ileal  coils 
becoming  infected  with  microbes  from  the  cecum. 
The  ileum  is  sterile  in  health,  and  is  not  equipped  by 


Pig.  7. — Atheromatous  elongation  and  dilatation  of  the 
aortic  arch,  in  a  "stasis"  subject.  The  dotted  line  is  in  the 
long  axis  of  the  heart,  more  oblique  than  normal  in  conse- 
quence of  the  aortic  elongation.  No  tissue  escapes  the  dele- 
terious action  of  the  intestinal  toxins. 


12 


Fig.  8. — Stomach  and  duodenum,  taken  on  the  couch  after 
a  bismuth  meal  in  a  man  aged  47,  suffering  from  mucous 
colitis  and  a  rheumatoid  left  hip.  Both  had  persisted  for  a 
year.  There  had  been  no  symptoms  referable  to  the  stomach 
or  duodenum.  The  first  part  of  the  duodenum  is  much  di- 
lated and  tensely  filled,  ending  below  in  a  blunt  point  beyond 
which  no  bismuth  was  seen  to  pass.  The  obstruction  was 
due  to  spasm  set  up  by  a  duodenal  ulcer  (in  the  position  of 
the  arrows).  C,  P,  cardiac  and  pyloric  portions  of  the  stom- 
ach ;  Py.,  pylorus  ;  a,  the  first  part  of  the  duodenum  ;  U,  the 
umbilicus    (see   also   Figs.    9-12). 

Nature  to  deal  with  microbic  invasion,  while  the 
large  intestine  can  cope  with  a  considerable  amount 
of  bacteria. 

The  absorption   of  poisons   into   the   circulation 


Fid.    9  — Showing  the  pyloric  end   of  the  stomach   and  the 
dilated  first  part  of  the  duodenum  in  the  subject  of  Fig.  8. 


13 


Fig.  10. — Taken  on  the  couch  6  hours  after  the  same 
bismuth  meal,  showing  ileal  stasis.  There  was  still  a  little 
bismuth  in  the  stomach,  and  the  dilated  first  part  of  the  duo- 
denum (a)  was  again  shown  well  filled  with  bismuth  en- 
trapped above  the  ulcer  (arrows).  U,  umbilicus;  the  X 
marks  the  ileocecal  entrance. 

enables  these  poisons  to  gain  access  to  every  organ 
and  tissue  of  the  body,  and  no  tissue  escapes  their 
baneful  influence.  Thus  we  get  many  of  the  gen- 
eral symptoms  of  stasis;  the  headache  and  de- 
pression, the  aching  muscles   and  joints,  the  un- 


Fig.  11. — Taken  9y2  hours  after  the  same  bismuth  meal, 
showing  the  same  conditions  as  Fig.  10  (q.v.).  The  appendix 
appeared  healthy. 


14 


healthy  skirl,  etc.  The  glands  suffer  early,  one  of 
the  first  changes  due  to  stasis  being  in  the 
breasts,  which  become  nodular.  The  condition  of 
the  breasts  is  a  very  good  index  for  gauging  the 
progress  of  a  "stasis"  patient  while  under  treatment. 
In  neglected  cases  chronic  cystic  disease  appears  in 
the  breasts, and  finally  they  become  cancerous  (Figs. 
1  and  2).  Other  glands  suffer,  and  the  pancreas  is 
found  to  be  hard  and  nodular  in  operations  for  sta- 
sis.    Cancer  of  the  head  of  the  pancreas  may  be  the 


Pig.  12. — Taken  26  hours  after  the  same  bismuth  meal, 
showing  evidence  of  mucous  colitis,  the  latter  portions  of  the 
transverse  colon,  and  the  whole  of  the  descending  and  iliac 
colon  being  in  a  state  of  tonic  contraction,  and  holding  only 
an  irregular  thin  line  of  bismuth,  mixed  with  mucus.  The 
iliac  colon  is  firmly  fixed  in  the  left  iliac  fossa  at  one  point, 
constituting  a   well-marked   "last   kink"    (Lane). 

last  stage  in  the  history.  The  suprarenal  glands 
probably  suffer  a  similar  change,  and  many  cases  of 
glycosuria  result  from  changes  in  the  pancreas  and 
the  suprarenals  (Figs.  3-6).  The  pigmentation  of 
the  skin  of  stasis  subjects  is  probably  due  to  supra- 
renal changes.  Other  ductless  glands  are  affected; 
the  thyroid  gland  atrophies,  or  else  undergoes 
changes  leading  to  exophthalmic  goiter.  The  sur- 
est proof  that  these  diseases  are  due  to  stasis  is  the 
fact  that  they  clear  up — permanently — on  the  cure 
of  the  stasis,  whether  by  operation  or  by  treatment, 

15 


Atheromatous  elongation,  and  later  dilatation  of  the 
aortic  arch  occurs  at  an  early  age  in  the  subjects  of 
intestinal  stasis ;  this  change  is  easily  recognized  by 
radiology,  and  is  capable  of  accurate  measurement 
(Figs.  7  and  15).  The  walls  of  the  aorta  evidently 
share  the  deterioration  of  all  the  tissues.  It  is  in- 
teresting to  speculate  how  far  changes  in  the  pitui- 
tary gland,  leading  to  raised  blood  pressure,  act  as 
the  exciting  cause  of  the  dilatation  of  the  aorta. 
Rheumatoid  arthritis  is  a  frequent  result  of  stasis, 
and  is  relieved  permanently  on  the  abolition  of  the 
stasis  (Figs.  8  and  24). 


Fig.  13. — Typical  chronic  ulcer  of  the  lesser  curvature  in  a 
woman,  aged  58,  taken  on  the  couch  after  a  bismuth  meal, 
showing  the  depressed  base  of  the  ulcer,  and  the  tight  spas- 
modic constriction  of  the  circular  fibers  of  the  stomach  over 
the  ulcer.  As  usual  there  was  persistent  spasm  at  the  py- 
lorus, with  dilatation  and  dropping  of  the  pyloric  portion  of 
the  stomach.  The  duodenum  was  elongated  and  dilated,  es- 
pecially its  first  part ;  it  showed  marked  "writhing"  contrac- 
tions, with  repeated  regurgitation,  only  small  amounts  en- 
tering the  jejunum  in  spite  of  the  strong  duodenal  peristalsis. 
After  24  hours  fully  one-third  of  the  bismuth  was  still 
in  the  pyloric  portion  of  the  stomach.  C,  P.  cardiac  and 
pyloric  portions  of  the  stomach  ;  U,  umbilicus  ;  Py.,  pylorus ; 
a.b.c,  first,  second  and  third  parts  of  the  duodenum.  The 
arrows  indicate  the  persistent  pyloric  spasm,  resembling  or- 
ganic stenosis   (see  also  Fig.  14). 

The  microbes  which  have  entered  the  stagnant 
ileum  from  the  cecum  ascend  to  the  upper  reaches 
of  the  small  intestine.  Thus  the  duodenum  becomes 
infected,  and  the  ducts  which  open  into  it  cannot 
escape  infection.  In  this  way  we  get  the  gall- 
bladder infected;  it  becomes  distended,  and  gall- 
stones are  formed  in  it. 

This  brings  us  to  another  aspect  of  stasis — one 
of  the  most  important  of  all,  and  the  one  which  is 


16 


still  most  open  to  doubt  by  the  medical  public,  al- 
though the  facts  are  so  clear  that  there  is  no  room 
for  doubt.  I  refer  to  the  effects  of  intestinal  stasis 
upon  the  duodenum  and  the  stomach.  In  studying 
this  part  of  the  subject  radiology  is  able  to  give  the 
greatest  assistance,  and  the  changes  revealed  by  a 
bismuth  meal  are  most  striking  and  characteristic. 
I  have  already  described  the  appearance  and  be- 
havior of  the  normal  duodenum.  In  stasis  the  state 
of  affairs  is  quite  different:  the  duodenum  is  much 
too  large ;  its  vertical  part  measures  4,  5,  or  even  6 
inches  in  length  instead  of  2%-31/4   inches,  as  in 


Fig.  14. — Taken  on  the  couch  47  hours  after  the  same 
bismuth  meal,,  showing-  bismuth  still  present  in  the  pyloric 
portion  of  the  stomach  and  in  the  depressed  base  of  the  ulcer. 
There  was  an  ileal  kink  ;  the  appendix  was  normal.  There 
was  great  stasis  in  the  large  intestine,  and  at  the  end  of  72 
hours  most  of  the  bismuth  was  still  in  the  cecum,  the  ascend- 
ing colon  and  the  dropped  transverse  colon.  (Confirmed  by 
operation  by  Sir  Arbuthnot  Lane,  and  all  the  symptoms — both 
general  and  those  due  to  the  gastric  ulcer — relieved  by 
"short-circuiting"  the  ileum  into  the  rectum.  The  stom- 
ach was  not  touched.  Six  months  later  she  was  at  work, 
feeling  quite  well.)  P,  pyloric  portion  of  stomach;  II.,  ileum; 
S.  F.,  splenic  flexure  ;  I.  C,  iliac  colon.  The  X  marks  the 
ileocecal  entrance. 

healthy  subjects.  These  measurements  are  taken 
orthodiagraphically,  so  they  are  strictly  comparable. 
The  duodenum  is  also  much  wider  than  normal; 
often  it  is  double  the  normal  width.  Its  first  part  in 
particular  is  often  greatly  dilated.  The  increased  size 
of  the  duodenum  is  not  the  only  change,  though  it 
is  a  sufficiently  striking  one.  Far  more  remarkable 
is  its  altered  behavior.  It  fills  well  with  bismuth 
(provided  the  conditions  be  arranged  suitably),  but 
it  does  not  empty  itself  into  the  jejunum  with  a 
single   peristaltic   wave   as    in   normal   cases;    the 


17 


Fig.  15. — Taken  on  the  couch  after  a  bismuth  meal  in  a 
woman  aged  60,  showing  a  carcinoma  of  the  stomach.  The 
x-ray  appearances  are  those  of  chronic  ulcer  in  caricature. 
The  wire  marks  the  outline  of  a  tumor  which  was  felt.  The 
duodenum  was  dilated,  and  showed  well-marked  "writhing" 
contractions.  The  aortic  arch  showed  considerable  athero- 
matous elongation,  and  slight  fusiform  dilatation.  C,  P, 
cardiac  and  pyloric  portions  of  the  stomach ;  Py.,  pylorus ; 
a,  b,  c,  first,  second  and  third  parts  of  the  duodenum ;  U, 
umbilicus.  Undoubtedly  the  tumor  originated  in  a  chronic 
ulcer  of  the  lesser  curvature,  though  the  deviation  from  the 
typical  form  is  considerable,  the  tumor  being  a  large  one. 

"static"  duodenum  shows  excessively  powerful  peri- 
stalsis,   wave   after    wave    passing    along    its    four 


Fig.  16. — Cancer  of  the  pelvic  colon,  taken  on  the  couch  96 
hours  after  a  bismuth  meal  in  a  man  aged  56.  I.  C,  iliac 
colon  ;  the  arrows  show  the  seat  of  obstruction  in  the  pelvic 
colon. 


18 


parts;  one  has  only  to  look  at  it  to  realize  that  it  is 
working  against  an  obstruction;  the  bismuth  is 
driven  down  to  the  lowest  part  of  the  duodenum, 
and  often  well  on  into  the  fourth  part,  only  to  re- 
turn again,  time  after  time,  to  the  vertical  part  as 
each  wave  passes  over.  The  whole  duodenum  alters 
in  form  continually  during  the  occurrence  of  this 
phenomenon,  giving  the  appearance  of  "writhing." 
In  severe  cases  this  "writhing"  peristalsis  continues 
hour  after  hour,  a  single  spurt  of  bismuth  finding 
its  way  through  to  the  jejunum  every  ten  minutes 
or  so.  The  duodenum  seems  never  to  tire.  Of 
course  it  should  be  understood  that  all  stages  occur 
between  the  normal  duodenum  and  the  extremely 
dilated,  writhing  duodenum  of  severe  stasis. 

What  proof  have  we  that  the  static  duodenum  is 


I   Opaaue 
_£.tteTncz 


Rec  turn. 


Fig.  17. — Taken  after  Pig.  16,  the  rectum  having  been 
filled  with  barium  fluid,  to  show  the  obstruction  in  the  pelvic 
colon. 

due  to  the  downward  pull  on  the  commencement  of 
the  jejunum  caused  by  overloading  of  the  lower  ileal 
coils?  The  proof  is  manifold  and  complete.  In  the 
first  place  the  downward  pull  on  the  jejunum  can  be 
observed  at  operation.  The  top  of  the  jejunum, 
moreover,  is  found  empty,  and  often  it  is  the  sub- 
ject of  torsion,  the  effect  of  the  duodenojejunal 
kink  being  increased  greatly  by  this  torsion.  The 
radiologist,  while  examining  the  duodenum,  can 
actually  see  the  bismuth  forced  into  the  fourth 
part  of  the  duodenum,  almost  up  to  the  junction 
with  the  jejunum ;  eventually  some  bismuth  is 
forced  through,  and  then  the  radiologist  can  see 


19 


Fig.  18.— "Diverticulitis"  of  the  pelvic  colon  in  a  man 
aged  54.  Severe  symptoms,  including  albuminuria  and  a  high 
blood  pressure,  were  relieved  by  the  operation  of  "short- 
circuiting"  carried  out  by  Sir  Arbuthnot  Lane. 

that  the  jejunum  passes  down  vertically  at  its  com- 
mencement. A  few  hours  later  he  is  able  to  con- 
vince himself  that  there  is  stasis  in  the  lower  coils 
of  the  ileum.  Few  things  in  medicine  are  more 
constant;  if  we  find  a  distended  duodenum  we  are 
certain  to  find  ileal  stasis,  and  conversely,  if  we 
find  a  normal  duodenum,  with  free  duodenojejunal 
junction  we  are  most  unlikely  to  find  any  material 
amount  of  stasis  in  the  lower  ileum.  The  proof  is 
more  perfect   even   than   this:   there   is   a   definite 


Fig.  19. — Ileal  kink  in  a  man  aged  57,  taken  on  the  couch 
10 Vi   hours  after  a   bismuth  meal.      (See  also  next  Fig.) 


20 


quantitative  relation  between  the  amount  of  ileal 
stasis  and  the  amount  of  duodenal  distention;  thus 
a  high  degree  of  duodenal  distention  will  be  found 
associated  with  great  ileal  stasis,  while  slight  duo- 
denal distention  goes  with  slight  ileal  stasis.  Of 
course  the  proportion  is  not  mathematically  accu- 
rate, but  it  is  nearly  enough  so  to  furnish  clinching 
proof  of  the  dependence  of  duodenal  distention  on 
ileal  stasis. 

The  distended  duodenum  causes  no  subjective 
symptoms,  but  if  it  is  congested  the  patient  be- 
comes aware  of  its  presence  at  once;  he  feels  pain 
in  this  region,  and  there  is  tenderness  to  pressure 
over  it;  the  tenderness  is  often  attributed  to  the 
gall-bladder.    If  the  duodenum  has  become  infected 


Fig.  20. — Taken  47  hours  after  the  same  bismuth  meal, 
showing  obstruction  by  bands  just  beyond  the  hepatic  flexure. 
(Confirmed  by  operation.) 

with  microbes  from  the  stagnant  ileum  we  shall 
probably  get  ulceration  in  the  duodenum  (Figs. 
8-12).  No  normal  duodenum  gets  ulcerated;  a 
chronic  duodenal  ulcer  occurs  only  in  the  distended 
duodenum  of  chronic  intestinal  stasis.  It  follows 
that  one  cannot  have  a  duodenal  ulcer  without  ileal 
stasis,  and  this  accords  entirely  with  my  experience. 
The  distended  duodenum  has  a  very  definite  ef- 
fect on  the  pylorus,  which  closes  tight  to  prevent 
reflux  from  the  overfull  duodenum.  The  pylorus 
gets  into  a  state  of  permanent  spasm  (Fig.  13),  its 
contents  become  too  acid,  and  this  leads  to  a  further 
increase  of  the  spasm,  for  physiological  experiments 

21 


have  proved  that  no  acid  can  enter  the  duodenum 
without  setting  up  an  immediate  tight  closure  of 
the  pylorus.  There  is  delay  in  the  emptying  of 
the  stomach,  and  this  organ  is  overloaded  and  di- 
lates. The  great  curvature  drops,  and  the  trans- 
verse colon,  also  heavy  with  the  weight  of  its  stag- 
nating contents,  drops  with  it.  Thus  we  get  an 
abnormally  great  strain  on  the  lesser  curvature,  and 
especially  on  the  two  "ligaments"  of  the  stomach — 
the  pylorus  and  the  esophagus.  A  chronic  ulcer  is 
apt  to  appear  at  the  pylorus,  this  part  being  accessi- 
ble to  the  microbes  which  infect  the  "static"  duo- 


• 

7  , 

D 

.9 
J 

e 

•  Caecum   1 

-  ,^rrt 

-, 

Fig.  21. — Cancer  of  the  ascending  colon  in  a  man  aged  57. 
There  was  a  movable  tumor  in  the  position  marked  by  a 
wire.  A  thin  streak  of  bismuth  ran  along  the  outer  side  of 
the  ascending  colon,  the  tumor  being  attached  to  the  inner 
wall.  The  appendix  (normal)  is  shown  well  filled  with  bis- 
muth. 

denum,  or,  if  the  pylorus  drops,  the  point  of  great- 
est strain  is  shifted  toward  the  esophagus,  and  the 
ulcer  appears  at  some  point  along  the  lesser  curva- 
ture (Figs.  13  and  14). 

With  the  appearance  of  an  ulcer  in  the  stomach 
the  acidity  of  the  gastric  contents  increases  still 
more,  and  the  pyloric  spasm  becomes  so  severe  and 
constant  as  to  simulate  organic  stenosis  (Figs.  13 
and  14),  and  the  radiologist  must  be  very  wary  in 
the  manner  of  carrying  out  his  investigations  to 
avoid  this  pitfall. 

The  ar-ray  appearances  of  chronic  ulcer  of  the 
lesser  curvature  are  quite  characteristic,  especially 
on  the  couch.    The  depressed  base  of  the  ulcer  fills 


22 


with  bismuth;  the  raised  margins  of  the  ulcer  are 
shown,  and  there  is  a  tight  hour-glass  constriction 
of  the  stomach  over  the  region  occupied  by  the  ul- 
cer, so  that  the  stomach  appears  divided  into  two 
parts,  separated  by  a  narrow  isthmus  (Fig.  13). 
An  important  point  to  remember  is  that  this  hour- 
glass constriction  is  permanent  except  during  gen- 
eral anesthesia.  The  radiologist  must  bear  this  in 
mind,  lest  he  diagnose  a  cicatricial  contraction,  and 
the  surgeon  must  not  forget  it,  for  when  operating 


Fig.  22. — Taken  11  hours  after  a  bismuth  meal  in  a  woman 
aged  35,  short-circuited  a  year  previously  by  Sir  Arbuthnot 
Lane.  Showing  the  termination  of  the  ileum,  and  the  rectum 
fu'l  of  bismuth.  Some  bismuth  had  run  up  to  the  splenic 
flexure ;  the  following  morning  this  had  come  down  again. 
II.,  ileum  ;  I.  C,  iliac  colon  ;  the  X  marks  the  union  between 
the    ileum   and    the    rectum. 

under  general  anesthesia  he  does  not  see  a  constric- 
tion, and  he  may  not  realize  that  the  stomach  will 
be  drawn  in  again  at  the  seat  of  the  ulcer  as  soon 
as  the  patient  has  recovered  from  the  anesthetic. 
I  have  seen  a  surgeon  make  his  gastrojejunostomy 
opening  at  the  level  of  a  chronic  ulcer  of  the  lesser 
curvature  and  the  result  was  promptly  fatal. 

If  we  were  to  make  an  artificial  hour-glass  con- 
striction in  a  healthy  stomach  we  should  expect  the 
pyloric  portion  of  that  stomach,  beyond  the  con- 
striction, to  become  small  (for  it  would  never  be 
properly  filled),  just  as  the  entire  stomach  becomes 


23 


small  in  cases  of  stricture  of  the  esophagus.  The 
fact  is  exactly  the  apposite  in  chronic  ulcer  of  the 
lesser  curvature;  the  pyloric  portion  of  the  stomach 
is  always  large  and  dropped  (Fig.  13)  ;  in  the  most 
extreme  cicatrical  hour-glass  stenosis  of  the  stomach 
the  great  curvature  may  be  in  the  pelvis  in  the  up- 
right posture.  This  affords  the  most  striking  con- 
firmation of  the  fact  that  the  chronic  ulcer  of  the 
lesser  curvature  occurs,  not  in  a  healthy  stomach, 
but  in  the  enlarged  stomach  produced  by  constant 
pyloric  spasm. 


Fig.  23. — Taken  5  hours  after  a  bismuth  meal  in  a  woman 
aged  26,  nine  months  after  colectomy.  All  the  bismuth  is  in 
the  rectum  except  traces  in  the  last  four  inches  of  the  ileum. 
The  duodenal  distension  and  the  pyloric  spasm  had  been  re- 
lieved almost  completely. 

The  symptoms  caused  by  these  chronic  gastric  ul- 
cers are  often  vague  and  difficult  to  interpret  clin- 
ically, and  they  are  not  often  diagnosed  correctly  ex- 
cept by  the  rc-ray  method,  when  the  diagnosis  can 
be  made  with  certainty  as  a  rule.  One  of  the 
dangers  of  leaving  these  ulcers  untreated  is  due  to 
their  tendency  to  become  malignant  after  a  time, 
and  I  have  a  number  of  instances  of  carcinoma  of 
the  stomach  exemplifying  various  stages  in  the 
transition  from  a  typical  chronic  ulcer  to  an  ex- 
tensive malignant  growth.  The  x-ray  appearances 
are  those  typical  of  a  chronic  ulcer,  but  with  more 
or  less  deviation  from  the  typical  picture  due  to 
the  malignant  involvement  (Fig.  15). 


24 


Thus  intestinal  stasis  is  shown  to  be  an  impor- 
tant cause  of  cancer,  not  only  in  the  stomach,  but 
also  in  the  pancreas,  the  liver  and  bile-ducts,  and 
in  the  breasts.  Cancers  occur  also  in  the  large  in- 
testine as  the  result  of  stasis ;  this  is  readily  shown. 
In  the  rectum  (Figs.  16  and  17)  and  in  the  cecum 
(Fig.  21)  the  long-continued  irritation  of  stag- 
nant feces  is  responsible  for  the  growth;  in  the 
hepatic  flexure  region  and  in  the  first  part  of  the 
transverse  colon  immediately  beyond  the  hepatic 
flexure  fecal  accumulation  is  often  due  to  bands 
continued    down    from    the    lower    surface    of    the 


Fig.  24. — Rheumatoid  arthritis  ;  a  disease  frequently  seen 
in  the  subjects  of  chronic  intestinal  stasis.  The  cancellous 
tissue  of  the  bones  is  rarefied.  The  joint  trouble  subsides 
permanently  on  the  relief  of  the  stasis. 

liver  over  the  pylorus  and  gall-bladder  (Fig.  20). 
These  bands  are  found  in  a  fair  proportion  of 
stasis  subjects.  The  iliac  colon,  again,  is  often 
tied  to  the  left  iliac  fossa  by  bands,  these  being 
the  first  to  form  in  the  body.  These  bands  some- 
times cause  obstruction  and  lead  to  a  condition  of 
chronic  congestion  with  yielding  of  the  bowel-wall 
between  the  bands  and  the  production  of  the  dis- 
order known  as  "diverticulitis"  (Fig.  18).  Follow- 
ing upon  this  long-continued  obstruction  we  may 
get  the  appearance  of  a  cancer  in  this  region. 

Needless  to  say  the  bearing  of  all  this  new  knowl- 
edge on  treatment  is  of  the  greatest  importance. 

I  propose  to  say  but  little  concerning  treatment, 

25 


and  only  in  its  relation  to  radiology.  Having  ascer- 
tained the  existence  of  stasis  in  a  particular  case, 
and  the  presence  of  one  or  more  of  its  complica- 
tions, the  question  will  always  arise — should  we  go 
to  the  root  of  the  matter  and  deal  with  the  stasis, 
or  should  we  apply  our  treatment  to  the  complica- 
tion,— the  end  result  of  the  stasis — e.g.  a  gastric 
or  duodenal  ulcer.  The  answer  is  simple: — leave 
the  end  result  alone  if  you  can,  i.e.  if  it  is  not 
causing  stenosis,  or  becoming  malignant,  or  im- 
pacted in  the  case  of  gallstones.  If  you  treat  the 
end  result  {e.g.  by  performing  a  posterior  gastro- 
jejunostomy for  ulcer)  you  will  give  your  patient 
temporary  relief  which  may  be  great,  but  you  will 
not  cure  his  stasis.  Or  again,  if  you  merely  remove 
his  appendix,  which  has  become  (secondarily)  con- 
gested or  kinked,  no  lasting  benefit  will  result.  In 
proof  of  this  I  would  mention  the  very  large  num- 
ber of  patients  sent  to  me  for  investigation  by  the 
x-rays  at  some  period  after  one  of  these  operations 
had  been  performed.  They  are  sent  to  me  because 
they  are  not  cured;  they  are  suffering  from  the' 
general  symptoms  and  signs  of  stasis;  or  perhaps 
some  other  complication  has  arisen,  e.g.  colitis. 

The  rational  treatment  of  stasis  is  directed  to 
the  abolition  of  the  undue  retention  of  the  con- 
tents of  the  lower  ileum  and  the  large  intestine. 
In  slight  cases  this  may  be  done  by  the  adminis- 
tration of  liquid  paraffin  to  accelerate  the  progress 
of  the  feces  through  the  large  intestine,  and  by 
a  spring  support  for  the  lower  abdomen,  to  pre- 
vent the  dropping  of  the  large  intestine  and  the 
lower  coils  of  the  ileum,  and  to  obviate  the  evil 
consequences  of  an  ileal  kink  if  there  be  one. 

In  severe  cases  of  stasis,  too  advanced  to  gain 
sufficient  relief  from  the  above  treatment,  operative 
measures  are  needed;  short-circuiting  the  ileum, 
near  its  lower  end,  into  the  rectum,  and  making  a 
kink  in  the  iliac  colon  above  the  short-circuit  to 
prevent  or  diminish  the  regurgitation  of  the  ileal 
contents  from  the  rectum  into  the  descending  colon. 
Often  there  is  already  a  well-developed  kink  in  this 
region  (Fig.  12),  or  there  is  a  slight  kink  which  can 
be  made  more  effective  at  the  operation.  In  some 
cases,  where  the  large  intestine  is  very  unhealthy,  and 
would  cause  flatulent  distension  and  other  trouble 
if  left,  Sir  Arbuthnot  Lane  now  removes  the  whole 
big  bowel  above  the  short-circuit  opening  at  the 
time  of  the  first  operation.  Formerly  he  would  do 
this  at  a  subsequent  operation  if  it  proved  neces- 

26 


sary;  with  increased  experience,  however,  one  is 
now  able  to  judge,  in  a  particular  case,  whether 
the  big  bowel  must  be  removed,  or  may  be  retained. 
All  the  details  of  the  operations  have  been  de- 
scribed by  Lane,  and  are  now  well  known  and  are 
practised  extensively  by  a  number  of  prominent 
surgeons  throughout  the  world. 

We  come  now  to  the  results  of  the  radical  treat- 
ment of  stasis  from  the  radiological  standpoint: 
Can  we  show,  by  radiology,  that  the  stasis  has  been 
relieved?  Certainly  we  can;  in  a  successful  case 
the  whole  bismuth  meal  is  in  the  rectum  after  6  or  8 
hours  (Fig.  23).  The  stasis  has  been  cured.  If 
the  large  intestine  has  been  left  there  may  be  some 
bismuth  in  the  descending  colon  for  a  few  hours 
(Fig.  22),  but  as  soon  as  the  patient  has  an  evacu- 
ation this  comes  down  and  is  passed  with  the  rest. 
Some  of  the  cases  in  which  the  bismuth  passes  back, 
not  merely  into  the  descending  colon  but  right  back 
to  the  cecum,  are  those  in  which  the  subsequent  re- 
moval of  the  big  bowel  becomes  necessary  on  account 
of  flatulent  distension  and  tenderness  due  to  the 
irritation  set  up  in  the  bowel  wall  by  the  retention 
of  lumps  of  secretion  in  the  big  bowel. 

The  question  will  be  asked,  what  is  the  effect 
of  the  radical  cure  of  stasis  upon  the  distended  duo- 
denum? If  the  explanation  ascribing  the  "static" 
duodenum  to  the  downward  pull  on  the  upper  jeju- 
num be  the  true  one,  then  the  cure  of  the  ileal 
stasis  should  abolish  this  downward  pull,  and  should, 
therefore,  relieve  the  duodenal  distention.  Does 
it  do  so?  Yes.  I  have  reinvestigated  a  large  num- 
ber of  patients  after  short-circuiting,  at  varying 
intervals,  from  three  weeks  to  several  years,  and 
the  general  conclusions  are  as  follows:  The  duo- 
denal obstruction,  as  shown  by  "writhing"  contrac- 
tions, and  repeated  return  of  the  bismuth  toward 
the  pylorus,  are  relieved  at  once  by  the  3  or  4 
weeks  recumbency  following  the  operation,  and  do 
not  come  again  even  after  the  patient  has  resumed 
ordinary  conditions  of  life  and  work.  The  duo- 
denum does  not  return  at  once  to  its  normal  size, 
but  gradually — in  the  course  of  months — it  becomes 
smaller  and  shorter,  though  in  old,  neglected  cases 
the  duodenum  tends  to  remain  permanently  more 
"baggy"  than  normal;  but  the  chief  point  is  that 
the  duodenum  never  again  becomes  distended;  it 
is  no  longer  found  full  of  bismuth;  its  outlines  can 
be  sketched  only  by  observing  small  quantities  of 
bismuth  as  they  pass  through  it — which  they  do 

27 


without  delay — into  the  jejunum.  No  photograph 
of  the  "cured"  duodenum  can  be  taken,  in  marked 
contrast  to  the  state  of  things  before  the  opera- 
tion, when  a  most  striking  photograph  of  the  dis- 
tended duodenum  is  readily  obtained. 

Another  proof  of  the  efficacy  of  the  radical  treat- 
ment is  shown  in  the  stomach,  which  loses  its  con- 
stant pyloric  spasm,  so  that  the  rate  of  emptying 
of  the  stomach  becomes  normal,  or  nearly  so  with- 
in a  few  months  after  the  operation.  This  was 
exemplified  to  me  in  a  most  striking  way  recently 
when  I  reexamined  a  woman  six  months  after  she 
had  been  "short-circuited"  by  Sir  Arbuthnot  Lane. 
Before  the  operation  she  had  furnished  one  of  my 
most  striking  instances  of  the  distended,  "writh- 
ing" duodenum,  and  scarcely  any  bismuth  had  left 
the  stomach  after  6V2  hours.  Now  (6  months 
later)  the  whole  of  the  bismuth  was  in  the  rectum 
after  six  hours,  a  little  having  run  up  the  descend- 
ing colon,  and  the  whole  had  been  evacuated  within 
24  hours.  The  duodenum  could  not  be  photo- 
graphed, the  bismuth  passing  through  it,  little  by 
little,  without  difficulty,  so  that  the  duodenum  was 
never  seen  filled  with  bismuth,  in  striking  contrast 
with  its  behavior  before  the  operation.  Thus  the 
patient  has  been  relieved  of  all  the  signs  and  symp- 
toms of  stasis,  and  her  stomach  and  duodenum 
have  been  put  out  of  danger;  the  duodenum  is  no 
longer  infected  with  microbes  from  the  stagnant 
ileum,  and  the  duodenal  distension  and  overloading 
of  the  stomach  have  been  rectified. 

I  have  given  details  of  other  aspects  of  stasis  in 
a  contribution  to  the  International  Journal  of  Sur- 
gery, for  April,  1914,  with  a  series  of  skiagrams  il- 
lustrating many  of  the  changes  due  to  the  disease. 

Much  progress  is  being  made  on  both  sides  of 
the  Atlantic  in  our  understanding  of  Chronic  In- 
testinal Stasis,  but  there  is  still  scope  for  search- 
ing inquiry  by  surgeons,  clinicians,  radiologists, 
pathologists,  and  in  fact  all  medical  workers,  in  the 
realm  which  has  been  discovered  by  the  far-reach- 
ing observations  of  Sir  Arbuthnot  Lane. 

Here,  in  the  New  York  Polyclinic,  I  see  earnest 
investigators  at  work  on  the  stasis  problem.  Dr. 
Quimby  is  attacking  it  from  the  radiological  side, 
Dr.  Hayes  and  others  from  the  medical  and  patho- 
logical standpoint,  while  Dr.  William  Seaman  Bain- 
bridge  is  getting  brilliantly  successful  results  from 
the  application  of  surgical  measures  to  the  relief 
of  chronic  intestinal  stasis. 

28 


THYROID  DEFICIENCY. 

By  E.  HERTOGHE,  M.D., 

ANTWERP,   BELGIUM. 

CORRESPONDING     MEMBER     OF    ROYAL    ACADEMY    OP     MEDICINE    OF 
BELGIUM. 

Myxedema  in  the  severe  form  was  discovered  and 
first  studied  in  England.  It  is  now  a  well-known 
pathological  entity  all  over  the  world  and  of  it  I 
could  say  nothing  but  what  you  know  perfectly  well. 
But  I  will  insist  upon  the  mild  forms  because  they 
are  not  so  well  outlined  and  very  often  escape  the 
attention  of  the  medical  man.  I  called  it  when  I  de- 
scribed it  for  the  first  time  18991  mild  myxedema, 
myxedema  frustum,  or  benignant  chronic  hypothy- 
roidism. The  conception  of  mild  myxedema  was  at 
first  strongly  opposed  because  the  symptoms  were 
so  numerous,  that  is  to  say,  because  the  sympto- 
matological  range  was  so  great  and  extended  to 
every  organ  of  the  body.  Just  lately  Dr.  Leonard 
Williams  of  London  has  said:  "The  idea  of  benig- 
nant chronic  hypothyroidism  is  simple  enough,  but 
the  symptomatology  is  a  perfect  maze."  This  is 
not  the  fact,  provided  we  begin  with  a  clear  under- 
standing of  the  lesion  caused  by  thyroid  want. 

If  we  knew  exactly  the  function  of  the  thyroid 
gland  we  would  no  doubt  be  able  to  deduct  imme- 
diately the  symptom  of  a  diminished  or  impov- 
erished secretion;  but  we  do  not.  However,  we 
know  something.  We  know  that  without  the  thyroid 
stimulus  no  cell,  whatever  it  may  be,  can  attain 
its  morphological  perfection — the  perfection  needed 
for  good  work,  muscular,  nervous,  connective, 
glandular,  or  bone.  The  proof  thereof  is  that  a 
child  born  with  congenital  want  or  a  child  deprived 
completely  by  an  operation  of  its  thyroid  gland 
does  not  grow,  or  grows  very  little.  Give  it  a 
few  doses  of  thyroid  extract  and  it  will  begin  to 
develop;  stop  the  supply  and  immediately  progress 
is  stopped. 

We  know  something  more:  When  a  cell  has  done 
its  duty  for  some  time  it  decays,  it  is  no  longer 
desirable.  It  must  be  taken  to  pieces  and  elimi- 
nated through  various  channels — bowels,  kidneys, 

(Reprint  from  the  Medical  Record.) 
29 


lungs — especially  under  the  form  of  urea.  When 
thyroid  supply  is  scarce  the  carrying  away  of  the 
cellular  waste  matter  is  slow  and  incomplete — 
mucin,  fat,  and  other  principles  accumulate  on  the 
spot,  and  there  form  an  infiltration  and  edema  of 
a  special  kind — hard,  non-depressible — and  there- 
from comes  the  name  of  myxedema. 

Infiltration  Is  the  Constant  Lesion  of  Thyroid 
Deficiency. — It  may  be  obvious  or  it  may  be  slight, 
but  it  is  always  there.  If  a  patient,  swollen  with 
this  special  edema,  takes  thyroid  extract  he  im- 
mediately eliminates  a  great  quantity  of  urine  and 
urea.  He  loses  in  weight,  the  cellular  waste  matter 
is  carried  away,  and  when  he  has  got  rid  of  the 
whole  residual  stock  you  may  give  him  doses  ten 
times  stronger  and  he  will  lose  no  more.  We  may 
sum  up  and  say,  thyroid  secretion  is  necessary  to 
the  building  up  and  to  the  dismantling  of  our 
tissues — of  all  our  tissues ;  and,  therefore,  the  want 
of  it  finds  an  echo  in  all  our  organs  without  any 
exception. 

All  the  infectious  diseases  of  early  age  and  of 
later  on  fall  heavily  on  the  vitality  of  the  thyroid 
gland.  Acute  rheumatism  of  the  joints  has  a 
most  nefarious  influence  and  causes  even  after 
years  the  outbreak  of  severe  forms  of  myxedema. 
And,  what  is  more,  all  the  great  causes  of  patho- 
logical disturbance,  tuberculosis,  syphilis,  paludism, 
alcoholism,  chronic  starvation,  and  consanguinity 
hit  their  first  blow  on  the  thyroid  system,  and  the 
thyroid  deficiency  thus  brought  on  comes  down 
fatally  on  the  offspring. 

The  child  shown  in  Fig.  1  is  a  remarkable  in- 
stance of  hereditary  syphilis  and  thyroid  weak- 
ness. The  father  married  shortly  after  having 
contracted  syphilis.  The  result  you  see  here — 
growth  stopped,  cretinous  appearance;  observe  also 
the  result  of  medication. 

If  we  had  seen  such  a  patient  some  ten  or  fif- 
teen years  ago  we  would  have  no  doubt  diagnosed 
hereditary  syphilis,  but  there  would  have  ended  our 
healing  power — neither  iodine  nor  mercury  would 
have  restored  the  child  to  normal  growth  and 
health.  But  now  that  we  know  that  the  growth 
has  been  stopped  on  account  of  the  syphilitic  toxin 
having  dried  up  the  thyroid  well,  we  act  in  conse- 
quence and  have  a  successful  medication,  that  shows 
the  usefulness  of  the  hypothyroid  notion. 

The  litle  girl  shown  in  Fig.  2  is  a  case  of  thyroid 
weakness    caused    by    hereditary    paludism.      The 

30 


mother  while  pregnant  underwent  several  attacks 
of  intermittent  fever.  She  herself  had  a  weak 
thyroid.  The  paludic  poison  added  to  her  natural 
disposition  had  the  result  of  impairing  the  thyroid 
powers  of  the  child,  and  it  was  born  a  cretin.  This 
case  looked  at  as  merely  paludic  was  hopeless. 
Seen  in  the  light  of  thyroid  weakness  we  get  a 
good  result. 

The  boy  shown  in  Fig.  3  was  twenty-one  years 
old.  He  was  a  perfect  dwarf,  absolutely  childish, 
and  without  any  intellectual  development.  Mother 
healthy.     Father   died   from   pulmonary   consump- 


Fig.  1. — Hereditary  syphilis,  a,  Arrest  of  growth,  age  10%, 
height  3  ft.  2y2  in.  ;  b  and  c,  influence  of  thyroid  feeding 
after  1  and  after  2  years. 

tion  a  few  days  before  the  child  was  born.  This 
may  be  considered  as  a  case  of  hypothyroidism  and 
tuberculous  heredity. 

Let  us  bear  in  mind  that  we  are  inheritors  of 
a  great  number  of  generations.  Our  blood  is  a 
mixture  of  good  and  bad  qualities  that  our  fore- 
fathers have  left  us  while  struggling  with  in- 
numerable causes  of  diseases  of  all  sorts.  From 
all  this  we  may  conclude  that  thyroid  weakness  is 
very  frequent,  at  least  in  a  mild  form. 

Now  I  must  say  that  thyroid  weakness  is  not 
synonymous  with  cretinism.  Incomplete  forms  will 
go  very  well  with  a  fairly  active  and  busy  life; 
some  of  these  patients  are  indeed  very  intelligent. 
I  wish  to  draw  your  attention  to  these  social  forms 
because  they  are  very  common,  and  because  the 
exact  knowledge  of  them  enables  us  to  grasp  the 
cause   and    decide   the    successful    treatment   of   a 


31 


large  number  of  pathological  conditions  for  the 
occurrence  and  treatment  of  which  we  are  other- 
wise  unprepared. 

We  will  now  follow  up  the  idea  of  infiltration 
which  is  brought  on  by  thyroid  insufficiency,  and 
consider  the  consequences  in  various  tissues  of  the 
body. 

Muscles. — The  cell  loaded  with  fat  and  mucin  is 
increased  in  size  so  that  its  contraction  is  delayed 
in  onset  and  slow  in  execution.  Muscular  action 
then  becomes  painful,  accompanied  by  stiffness  and 
dread  of  movement.     The  connective  tissue  sheath 


a  b  c  d 

Fig.  2. — Hereditary  paludism.  a,  Arrest  of  growth,  age  8 
years,  height  2  ft.  10  in.  instead  of  3  ft.  10  in. ;  b,  c,  d,  influ- 
ence of  thyroid  feeding,  after  1,2,  5  years. 

which  supports  the  contractile  elements  and  con- 
nects the  muscles  with  the  tendons,  aponeuroses, 
and  articular  ligaments  is  equally  infiltrated,  and 
this  adds  to  the  difficulty  of  movement.  This  ap- 
plies alike  to  non-striped  and  voluntary  muscle. 

This  muscular  infiltration  shows  itself  subjec- 
tively by  rheumatoid  pains,  which  must  not  be 
confused  with  rheumatism,  due  to  causes  with 
which  we  are  not  here  to  be  concerned.  The  state- 
ment made  by  some  writers  that  thyroid  extract 
cures  nodular  rheumatism,  chronic  or  otherwise, 
should,  therefore,  be  accepted  with  reserve.  Thy- 
roid extract  relieves  pain  in  the  muscles,  joints, 
and  ligaments  only  in  so  far  as  this  depends  on 
thyroid  deficiency ;  that  is,  it  is  due  to  the  specific 
myxedematous  infiltration,  and  it  acts  only  by 
causing  absorption  of  that  infiltration.     We  must 


32 


remember  that  thyroid  extract  is  essentially  a  spe- 
cific and  can  act  favorably  only  where  there  exists 
an  inactivity,  or  weakness  of  the  thyroid. 

Let  us  take  another  example.  The  nerve  cell, 
whatever  may  be  the  degree  of  myxedematous  ca- 
chexia, is  never  destroyed  as  in  a  hemorrhagic  focus 
or  embolic  necrosis.  Its  nutrition  and  excretion 
are  simply  hindered.  It  is  infiltrated  and  at  the 
same  time  compressed  by  the  infiltration  of  its 
supporting  connecting  tissues.  The  transmission 
of  motor,  sensory,  and  voluntary  impulses  is  thereby 
delayed  but  not  abolished,  and  the  reflexes  are  slug- 
gish but  present. 

The  discomfort  of  the  nerves  shows  itself  by 
neuralgias  and  even  by  shooting  pains  of  a  neuritic 
character;  the  distinction  between  these  two  kinds 
of  pain  being  well  known  to  the  patient.  Cardiac 
pain  is  also  present  with  radiations  into  the  bra- 
chial plexus  simulating  attacks  of  angina. 

The  central  nervous  system  exhibits  early  evi- 
dence of  infiltration,  however  slight  it  may  be.  In 
well-marked  myxedema,  vertigo,  dizziness,  noises 
in  the  ears,  headache,  migraine,  loss  of  memory, 
mental  confusion,  depression,  melancholia,  loss  of 
consciousness,  loss  of  balancing  power,  sudden 
falls,  somnolence,  attacks  of  coma,  which  may  be 
confused  with  the  serous  apoplexy  of  Bright,  with 
all  the  more  probability  that  there  is  usually  some 
albuminuria. 

In  mild  myxedema  the  list  is  not  so  formidable. 
One  should  remember  the  morning  headaches  and 
tendency  to  migraine,  vertigo,  and  noises  in  the 
ears. 

Even  the  bone  does  not  escape  the  consequences 
of  thyroid  defect.  Every  surgeon  knows  that  in 
certain  persons  fractures  unite  imperfectly  or  not 
at  all,  and  thyroid  extract  is  given  to  avoid  com- 
plication. If  one  carefully  examines  such  patients, 
those  at  least  who  benefit  by  it,  there  will  always 
be  found  some  more  symptoms  of  thyroid  deficiency. 

Cartilaginous  tissue  also  gives  clear  evidence  of 
this  specific  cellular  infiltration.  On  moving  the 
joints  which  are  stiff  and  painful  the  application  of 
the  hand  detects  a  peculiar  sensation  resembling 
the  crackling  of  crushed  snow  which  is  almost 
pathognomonic.  This  is  well  felt  in  the  knee  joint. 
Sometimes  the  patient  himself  feels  and  hears  a 
crepitation  in  the  joints  of  his  cervical  vertebrae. 
These  joint  symptoms  were  described  first  by 
Professor  Verriest  in  connection  with  a  case  of 


33 


myxedema  shown  to  the  Royal  Academy  of  Medi- 
cine of  Belgium  in  1886." 

These  painful  affections  of  the  joints  improve 
very  slowly  and  are  the  last  symptoms  to  disappear. 
An  ecclesiastic,  after  several  months'  treatment  for 
very  pronounced  myxedema,  still  complained  of  the 
stiffness  of  his  knees  which  rendered  ritual  genu- 
flection very  difficult,  but  which  ultimately  com- 
pletely disappeared.  This  delay  in  functional  restor- 
ation may  perhaps  be  explained  by  the  slowness  of 
the  nutritive   exchanges    in  cartilage. 

The  glandular  tissues  which  play  so  important 


Fig.  3. — Hereditary  tuberculosis,  thyroid  weakness.  Arrest 
of  growth ;  influence  of  thyroid  feeding,  after  %,  1,  and  2 
years. 

a  part  in  the  organism  also  present  infiltration  both 
of  their  secreting  elements  and  the  supporting  con- 
nective tissue.  The  secretion  of  sweat  is  com- 
pletely abolished. 

There  is  considerable  congestion  of  the  liver,3 
the  hepatic  cells  secrete  badly,  while  the  canaliculi 
are  compressed.  Bile  passes  into  the  circulation, 
causing  the  characteristic  amber  color  of  the  skin. 
Biliary  calculi  are  also  common. 

The  scanty  intestinal  secretion  along  with  the 
muscular  weakness  of  the  visceral  walls  causes  ob- 
stinate constipation,  which  in  turn  leads  to  fermen- 
tation with  the  formation  of  an  abnormal  quantity 
of  gas,  thus  producing  meteorism  and  abdominal 
distention  with  noisy  eructations  from  the  stomach. 

The  alterations  of  epidermic  and  epithelial  cov- 
erings   deserve   special   notice.      The   insufficiently 


34 


nourished  epidermis  undergoes  early  desquamation; 
the  hair  falls  prematurely.  In  milder  cases  the  hair 
is  poor,  brittle,  and  becomes  early  grey,  while  the 
beard  is  thin  and  straggling.  The  nails  are  striated 
and  brittle,  and  in  severe  cases  split  and  destroyed. 
The  teeth  are  almost  always  in  a  deplorable  con- 
dition, exposed,  decayed,  and  covered  with  a  green- 


Fig.   4. — Hypothyroids  alopecia  ;  thyroid  insufficiency.     Influ- 
ence of  thyroid  feeding. 

ish  tartar.  The  gums  are  red  and  irritated,  form- 
ing polypoid  projections  between  the  teeth.  The 
eyebrows  are  thinned,  especially  in  their  outer 
thirds,  giving  the  face  a  somewhat  silly  expres- 
sion. The  eyelashes  are  also  shed,  leaving  the  eye- 
lids unprotected  against  the  erosive  action  of  the 
tears.  This  blepharitis  of  thyroid  origin  is  some- 
times seen  in  old  persons.  In  a  case  which  had  re- 
sisted all  other  means  of  treatment,  a  radical  cure 
was  obtained  in  a  few  days  by  the  local  applica- 
tion of  adrenalin  and  the  administration  of  thy- 
roid extract.     The  whole  skin   is  thickened,  infil- 

35 


trated,  cold,  and  easily  attacked  by  such  affections 
as  eczema,  psoriasis,  and  alopecia.  The  eczematous 
condition  of  the  scalp  in  young  infants,  known  as 
the  "milk  crust,"  which  is  alike  the  despair  of 
mothers  and  doctors,  yields  rapidly  to  a  few  doses 
of  thyroidin  combined  with  arsenic,  when  this  af- 
fection is  associated  with  thyroid  defect,  and  the 
same  can  be  said  of  psoriasis  and  of  certain  forms 
of  alopecia. 

The  little  boy  pictured  in  Fig.  4  had  lost  all  his 
hair.  I  should  never  have  suspected  thyroid  de- 
ficiency in  this  case  if  the  mother  had  not  evidently 
been  under  thyroid  distress.  The  result  of  thyroid 
treatment  on  growth  and  alopecia  is  well  shown.4 

The  mucous  membrane  of  the  mouth,  lips,  tongue, 
nose,  pharynx,  larynx,  ear  and  esophagus  are  also 
infiltrated. 

The  vaginal  mucous  membrane  is  softened  and 
infiltrated,  giving  on  digital  examination  a  sen- 
sation similar  to  that  of  the  commencement  of 
labor.  Similar  changes  produce  disturbances  of 
phonation,  deglutition  and  hearing. 

The  swelling  of  the  fauces  and  esophagus  may 
actually  prevent  swallowing  in  some  cases. 

In  very  severe  cases  of  advanced  myxedema,  at 
the  approach  of  death,  the  enormously  swollen 
tongue  tends  to  fall  backward  so  that  the  air  does 
not  enter  the  trachea,  although  the  respiratory 
movements  of  the  thorax  continue;  the  condition 
being  identical  with  that  seen  during  anesthesia  in 
similar  circumstances.  After  five  or  six  of  such 
false  inspirations  a  spasm  of  the  tongue  .and 
pharynx  occurs  which  again  allows  the  entrance 
of  air.  Normal  respiration  is  thus  reestablished 
for  a  time,  till  again  interrupted  and  restored  as 
before.  This  condition  may  be  mistaken  by  an  in- 
experienced observer  for  a  type  of  Cheyne-Stokes 
respiration. 

Endothelial  tissues  share  in  the  general  feeble- 
ness. They  are  shed  prematurely,  and  such  cavities 
as  the  gall-bladder  and  also  the  urinary  bladder 
are  unprotected  from  the  irritating  action  of  their 
contents.  The  gall-bladder  becomes  sensitive,  even 
painful,  while  the  mass  of  desquamated  epithelium 
may  become  the  nucleus  of  a  calculus.  Biliary 
lithiasis  is  itself  frequent  in  myxedema,  and  occurs 
to  a  less  extent  in  the  milder  forms. 

The  bladder  being  constantly  denuded  of  its 
epithelial  lining  is  more  than  usually  sensitive  to 
the  irritating  action  of  the  urine,  and  this  alone 

36 


is  responsible  for  many  cases  of  nocturnal  enuresis 
in  children.  An  examination  of  the  urine  in  these 
cases  shows  the  presence  of  a  large  number  of 
squamous  epithelial  cells  from  the  bladder.  When 
closely  studied  these  children  present  signs  of  thy- 
roid weakness,  and  their  parents,  especially  the 
mother,  often  exhibit  a  more  or  less  advanced  de- 
gree of  thyroid  defect.  As  the  children  grow  up 
the  activity  of  the  thyroid  gland  increases  and 
these  troubles  disappear.  In  girls  a  trace  of  them 
frequently  persists  as  pollakiuria  or  frequency  of 
micturition. 

A  most  constant  symptom  of  myxedema  is  a 
lowering  of  the  temperature.  This  may  be  due  to 
the  decreased  or  less  active  combustion  of  fats  and 


Ej 

4     %*M 

\ 



Fig.  5. — Severe  myxedema  before  and  after  treatment. 

mucin,  or  perhaps  to  the  infiltration  of  the  heat- 
regulating  center  in  the  brain.  If  one  suddenly 
administers  large  doses  of  thyroidin  to  a  myxe- 
dematous patient,  at  the  time  he  has  a  large  quan- 
tity of  infiltration  ready  to  be  oxidized,  one  may 
observe  a  considerable  elevation  of  temperature, 
which  may  even  be  mistaken  for  fever.  This  is 
probably  due  to  the  ultra-rapid  combustion  of  these 
accumulated  materials. 

The  lowering  of  the  body  temperature  is  per- 
ceived by  the  patient.  It  is  subject  to  diurnal  vari- 
ations, being  specially  noticeable  in  the  afternoon 
about  4  or  5  o'clock,  in  the  form  of  violent  shiv- 
ering, starting  with  the  sensation  of  cold  water 
thrown  on  the  back.  These  symptoms  may  be  mis- 
interpreted and  treated  by  the  useless  administra- 
tion of  quinine.  In  slight  myxedema  this  feeling 
of  cold  is  present  in  a  lesser  degree.  The  patient 
is  in  a  state  of  habitual  chilliness,  showing  itself 
in  women  and  children  by  constant  coldness  of  the 
hands  and  feet,  and  the  condition  known  as  "dead 

37 


finger" — pallor,  stiffness,  and  insensibility  of  one  or 
more  digits. 

Let  us  consider  the  effects  of  the  infiltration  on 
a  complex  mechanism,  such  as  the  cardiorespi- 
ratory system,  where  the  different  elements  we 
have  just  studied  are  associated  with  one  another. 

We  have  to  remember  the  paresis  of  the  cardiac 
muscle,  of  the  external  respiratory  muscles,  and 
of  the  diaphragm;  the  painful  infiltration  of  the 
nervous  ganglia  at  the  base  of  the  heart,  added 
to  the  disturbances  of  its  central  innervation;  the 
infiltration  of  the  pulmonary  tissue,  the  bronchial 
mucous  membrane  of  the  respiratory  tract,  and 
consider   the   consequences. 

The  dyspnea  presented  by  some  patients  suffer- 
ing from  severe  myxedema  may  surpass  all  de- 
scription. They  can  with  difficulty  climb  a  short 
flight  of  stairs,  even  with  a  rest  by  the  way;  they 
arrive  in  the  consulting  room  absolutely  breath- 
less and  supporting  themselves  by  the  furniture, 
indicating  by  signs  their  inability  to  speak  till 
they  have  recovered  breath. 

In  mild  cases  the  oppression  is  less  marked.  It 
may  be  intermittent  and  presented  only  on  the 
occasion  of  unusual  exertion,  corresponding  to  an 
increased  demand  on  the  thyroid  gland  which  is 
weak  already.  The  condition  is  then  readily  mis- 
taken for  an  attack  of  asthma,  and  many  so-called 
asthmatics  are  certainly  suffering  from  thyroid 
defect.  Certain  French  writers  have  reported  some 
unexpected  cures  of  asthma  by  thyroid  extract, 
and  while  admitting  that  the  patients  presented 
symptoms  of  thyroid  weakness  they  persist  in  de- 
scribing such  cases  by  the  term  neuroarthritic. 
That  is  not  logical;  we  should  rejoice  to  see  the 
word  arthritism,  which  no  one  understands  and 
which  is  so  often  used  as  a  cloak  for  ignorance, 
disappear  from  the  medical  vocabulary. 

Another  example:  Consider  the  gastrointestinal 
system — the  muscular  walls  are  slow  and  lazy,  in- 
testinal secretion  scarce,  therefrom  arises  consti- 
pation. Microbes  find  their  way  to  the  peritoneum 
and  even  kidneys;  the  peritoneum  protects  itself 
by  false  membranes  which  in  time  will  grow  into 
bands,  bringing  on  kinks  and  their  consequences. 
In  hypothyroid  patients  these  pericolitic  adhesions 
nearly  always  exist  and  are  even  found  in  very 
young  children,  which  is  not  to  be  wondered  at 
— hypothyroid  disposition  being  nearly  always 
hereditary. 

38 


I  would  be  delighted  if  my  supposition  concern- 
ing the  question  of  intestinal  stasis  should  prove 
to  be  correct.  It  would  perhaps  bring  into  a 
brighter  light  still  the  ideas  that  Sir  Arbuthnot 
Lane  in  England  and  Professor  Bainbridge  in 
America  have  promoted  and  implanted  at  the  price 
of  a  most  daring  and  incessant  effort. 

Sexual  System. — The  thyroid  gland  plays  an  im- 


Fig.  6. — Severe  myxedema  before  and  after  treatment. 

portant  part  in  the  development  and  functional 
activity  of  the  sexual  organs,  especially  in  females. 
It  superintends  the  growth  and  general  develop- 
ment of  the  sexual  organs.  Absolute  cretins  never 
come  to  puberty.  In  mild  forms  of  thyroid  in- 
sufficiency the  uterus  remains  infantile  and  small; 
menstruation  begins  late  in  life.  Sometimes  the 
posterior  wall  of  the  womb  does  not  grow  as  quickly 
as  the  anterior,  and  therefrom  comes  retroflexion. 
This  is  by  no  means  a  rare  condition  in  very  young 
girls.  Profuse  menstrual  bleeding  is  often  seen 
in  such  cases  and  is  attributed  to  retroflexion.  As 
a  matter  of  fact,  the  excessive  bleeding  is  caused 
by  the  infiltration  of  the  uterine  mucous  lining,  by 
the  defective  contractility  of  uterine  muscular 
cells  and  by  the  hemophilic  condition  of  the  blood. 
In  thyroid  defect  hemophilia  is  quite  a  classic  symp- 
tom. Profuse  oozing  may  be  brought  on  by  almost 
a  mere  scratch. 

It  is  a  well-recognized  fact  that  thyroid  defi- 
ciency falls,  in  nine-tenths  of  the  cases,  on  females. 
The  reason  thereof  is  easily  given:  The  thyroid 
has  a  great  influence  on  menstruation,  pregnancy, 


39 


lactation,  and  even  uterine  involution  after  child- 
birth. When  the  thyroid  is  normally  active  the 
menses  are  normal;  when  weak,  menorrhagia  sets 
in.  The  weaker  the  thyroid  the  greater  the  loss 
of  blood.  We  very  often  come  across  these  cases 
of  menorrhagia  even  in  very  young  girls,  and  we 
are  at  a  loss  to  understand  the  meaning  of  this 
distressful  condition.  We  do  not  know  what  to  do 
to  prevent  it.  If  we  can  put  aside  such  causes  as 
fibroids  and  cancer,  we  will  always  think  of  thyroid 
deficiency. 

A  large  quantity  of  thyroid  stuff  is  wanted  dur- 
ing the  menstrual  period,  and  during  that  time  can- 


Fig.  7. — Severe  myxedema  before  and  after  treatment. 

not  be  given  to  the  general  keeping  up  of  the 
body.  We  often  see  women  who  at  ordinary  times 
have  a  decent  supply  of  thyroid  secretion  run, 
short  during  the  menses,  and  show  then,  and  then 
only,  the  usual  signs  of  thyroid  defect.  Headaches 
(migraine)  are  almost  classic  symptoms  at  that 
time.  Many  women  have  muffled  voice,  which  is 
the  result  of  temporary  infiltration  of  the  vocal 
chords.  Extreme  lassitude,  pains  in  the  back,  ob- 
stinate constipation,  all  go  along  in  that  line  of 
symptoms. 

It  is  not  necessary  to  dwell  on  the  good  effects 
of  thyroid  medication  under  such  circumstances. 
A  few  doses  of  thyroid  extract  will  act  as  a  power- 
ful tonic  and  reduce  to  a  considerable  extent  the 
anemic  influence  of  the  menses,  and  reduce  con- 
siderably the  loss  of  blood. 

In  pregnancy  the  thyroid  becomes  enlarged  and 
throws  into  the  blood  an  unusually  large  quantity 


40 


of  secretion,  thereby  suspending  menstruation  and 
protecting  the  fertilized  ovum  against  the  harm 
which  would  result  from  menstrual  activity.  This 
action  of  the  thyroid  should  be.  remembered  in 
cases  where  chronic  abortion  has  exhausted  all 
other  forms  of  medication.  We  may  assert  that 
thyroid  extract  has  proved  in  scores  of  cases  an 
excellent  remedy  for  otherwise  inexplicable  ster- 
ility. A  great  many  women  who  have  taken  thy- 
roid extract  with  a  view  to  reduce  their  obesity 
have  been  surprised  by  becoming  pregnant  in  the 
course  of  this  medication,  and  this  unexpected  re- 
sult is  due  to  the  thyroid  inhibition  of  menstrua- 
tion. After  childbirth  the  maternal  system  is  sud- 
denly relieved;  a  large  amount  of  thyroid  secre- 
tion is  still  in  store.  Part  of  it  will  be  given  to  the 
muscular  and  nervous  exertion  of  labor  itself  and 
another  part  goes  to  the  involution  of  the  uterus. 
The  heavy  muscular  walls  of  the  womb  have  to  de- 
generate into  fat  and  be  oxidized,  and  this  can- 
not be  done  without  the  interference  of  the  thy- 
roid stimulus. 

Finally,  lactation  claims  a  good  deal  of  thyroid 
stuff.  It  has  been  proven  by  experiments  on  ani- 
mals that  thyroid  extract  works  upon  the  mammary 
glands  and  increases  the  quantity  of  milk.  Women 
who  have  a  good  lactation  have  also  a  quick  involu- 
tion of  the  womb.  After  weaning,  the  thyroid 
gland  is  now  fairly  exhausted.  Most  of  mothers 
grow  fat  at  that  time.  Menstruation  takes  advan- 
tage of  this  deficiency  and  comes  back.  Thyroid 
medication  may  be  useful  in  such  cases  where  lac- 
tation is  scanty  and  where  menstruation  has  a 
tendency  to  return  before  the  physiological  time. 
This  is  indeed  the  only  way  we  have  to  increase 
the  mammary  secretion. 

The  mucous  lining  of  the  vagina  is  also  infil- 
trated, and  under  examination  gives  the  impres- 
son  of  incipient  labor.  A  good  many  patients  have 
been  curetted  for  hemorrhagic  endometritis  who 
were  in  reality  deficient  in  their  thyroid  powers. 

I  acquainted  Professor  Bainbridge  when  he  was 
in  Antwerp  with  these  facts.  Being  a  gynecologist 
as  well  as  a  surgeon,  he  said  he  would  make  a  care- 
ful study  of  hypothyroid  menorrhagia.  I  am  glad 
to  say,  and  he  announced  it  before  the  Academy, 
that  he  is  now  convinced  that  this  is  absolute  truth. 
He  has  cured  a  number  of  cases  already  with  thy- 
roid feeding,  to  the  astonishment  of  those  who 
had  previously  curetted  the  uterus  without  reliev- 

41 


ing  the  menorrhagia.  Much  more  might  be  said 
about  thyroid  secretion,  indeed  volumes  have  been 
written  on  the  subject.  My  friend,  Dr.  Sajous  of 
Philadelphia,  knows  about  it,  and  his  work  on  in- 
ternal secretion  has  not  said  all. 

The  usefulness  of  thyroid  medication  is  con- 
spicuous in  delayed  development  of  the  sexual  or- 
gans, infantile  uterus,  infantile  retroflexion  and 
excessive  menstruation.  In  some  cases  of  sterility 
and  repeated  abortion  it  will  prove  to  be  a  success- 


Fig.  8. — Mild  myxedema,  showing  the  loss  of  heir. 

f ul  treatment.  Slow  involution  of  the  uterus  after 
childbirth  and  wavering  lactation  will  also  find  here 
powerful  help. 

From  what  we  have  stated  it  is  evident  that 
the  best  way  to  understand  mild  myxedema  is  to 
have  a  clear  conception  of  the  more  severe  form. 
The  more  severe  form,  when  properly  treated, 
gradually  progresses  through  the  milder  forms  to 
become  finally  imperceptible  even  to  the  most  ex- 
perienced eye.  So  also,  after  successful  treatment, 
a  myxedematous  patient,  left  to  himself,  gradu- 
ally relapses,  the  milder  symptoms  being  the  first 
to  return,  followed  by  those  of  increasing  severity, 
so  that  the  disease  reconstructs  itself  under  your 
eyes.      These  symptoms  of  the  milder  form  of  the 


42 


disease  are  precisely  those  which  should  be  most 
clearly  impressed  upon  your  memory. 

The  weakness  of  the  thyroid  gland  is  usually 
hereditary,  and  it  is  rare  that  one  does  not  find 
traces  of  milder  defect  among  the  ascending,  de- 
scending, or  collateral  relations  of  a  person  suffer- 
ing from  well-marked  myxedema.  One  must  in- 
quire carefully  into  the  family  history;  it  will 
be  found  an  inexhaustible  source  of  information 
regarding  symptoms  which  will  render  one  more 


Fig.   9. — The  same  patient  as  in  Fig.   8   after  treatment. 

familiar  with  the  milder  cases  of  hypothyroidism. 

In  doubtful  cases  treatment  by  thyroidin  forms 
the  touchstone  whether  for  mild  or  severe  myxe- 
dema. Many  persons  suffering  from  the  milder 
forms  do  not  appear  stout  or  swollen,  but  may 
even  be  quite  spare  in  body,  the  infiltration  in  such 
cases  predominating  in  the  internal  organs.  If 
under  small  doses  of  thyroidin  such  a  person  loses 
weight  with  simultaneous  improvement  in  his  gen- 
eral condition,  one  may  assert  the  existence  of  in- 
sufficient secretion  of  the  gland. 

Let  us  now  study  some  cases  of  advanced  myxe- 
dema, and,  to  facilitate  the  task,  permit  me  to  in- 
dicate the  course  I  myself  followed  at  the  begin- 
ning of  ray  studies  on  the  subject.     I  confess  that 


43 


when  I  first  found  myself  in  the  presence  of  a 
case  of  myxedema  I  knew  nothing  about  it.  I  had 
neglected  this  part  of  my  medical  studies,  believ- 
ing I  should  never  encounter  what  was  then  con- 
sidered a  pathological  rarity.  Myxedema,  which 
meant  nothing  to  me  in  1883  when  I  finished  my 
university  course,  interested  me  as  little  ten  years 
later,   when   circumstances    forced   me   to   concern 


Fig.   10. — Mild  myxedema — Loss  of  eyebrows. 

myself  with  it,  and  to  recognize  it  without  having 
suspected  its  existence. 

In  1894,  while  in  attendance  at  the  house  of  M.  X., 
he  confided  to  me  that  he  was  much  concerned  about 
the  health  of  his  wife.  He  informed  me  that  she  was 
64  years  of  age,  had  been  married  at  the  age  of  20, 
and  had  had  no  children.  She  had  been  delicate  all  her 
life,  but  recently  her  condition  had  been  so  much  worse 
that  he  feared  a  fatal  issue  was  rapidly  approaching. 
In  spite  of  this  she  absolutely  refused  to  consult  a 
doctor.  She  was  indifferent  to  all  that  went  on  around 
her,  this  apathy  being  combined  with  an  invincible  dis- 
inclination to  all  physical  exertion.  Speech  was  la- 
borious to  her,  being  slow,  faulty,  and  indistinct,  so 
that  usually  despairing  of  making  herself  understood, 
she  cut  short  all  attempts  at  conversation.     Her  only 


44 


desire  was  to'be  left  at  peace,  free  from  all  emotion  or 
anxiety. 

Soon  after  her  marriage  Mme.  X.  had  a  miscarriage. 
Her  menstruation  had  always  been  profuse  and  the  in- 
tervals between  the  periods  much  shortened;  the  men- 
strual loss  was  so  great  that  the  blood  soaked  through 
the  mattress  to  the  floor.     She  also  bled  easily  after 


Fig.   11. 


-Severe   myxedema   with   loss   of   hair, 
after  treatment. 


Before  and 


Fig.  12. — Profile  of  the  patient  shown  in  Fig.  11. 

slight  injuries,  a  simple  scratch  being  followed  by  pro- 
longed oozing.  These  repeated  hemorrhages  had  pro- 
duced a  state  of  pronounced  anemia  shown  by  the  pres- 
ence of  marked  pallor  and  weakness.  The  hemorrhages 
were  regarded  as  the  original  cause  of  her  con- 
dition. At  the  age  of  35,  while  driving  in  an  open  car- 
riage Mme.  X.  was  caught  in  a  heavy  shower  of  rain 
which  soaked  her  to  the  skin.  Following  this  she  took 
cold  and  suffered  from  a  well  denned  attack  of  acute 
articular  rheumatism,  from  which  she  recovered  but 
had  never  since  been  free  from  pain.  From  that  time 
her  condition  was  attributed  to  the  rheumatic  attack 
by  herself  and  her  friends. 

Such  was  the  information  given  me  by  the  husband, 
and  at  his  request  Mme.  X.  consented  to  see  me.  My 
diagnosis  was  instantaneous — it  was  evident  that  Mme. 


45 


X.  was  suffering  from  an  attack  of  Bright's  disease 
in  its  last  stage  (Fig.  5).  The  face  was  swollen,  the 
eyelids  were  edematous,  leaving  only  a  narrow  space 
between  them,  the  lips  were  thick,  everted,  and  bluish 
in  color,  the  speech  was  slow  and  drawling,  the  voice 
having  a  strange,  deep,  croaking  tone,  while  the  gait 
was  awkward  with  slow  and  indecisive  movements.  I 
communicated  my  opinion  to  her  husband  and  in- 
timated my  fear  that  a  fatal  termination  was  threaten- 
ing from  uremia.  M.  X.  was  not  surprised  and  told 
me  that  all  the  doctors  previously  consulted  had  been 
of  the  same  opinion.     I  then  examined  the  urine  and  to 


Fig.  13. — Severe  myxedema ;  baldness  of  the  nape 

my  great  astonishment  it  contained  only  an  insig- 
nificant quantity  of  albumin — about  1%  grains  to  the 
ounce.  There  was  no  renal  epithelium  present,  but 
squamous  cells  from  the  bladder  were  abundant.  I 
was  much  embarrassed  at  finding  a  case  of  Bright's 
disease  which  had  reached  the  stage  of  threatened 
uremia  practically  without  change  in  the  urine.  Next 
day  I  explained  to  M.  X.  that  the  case  was  somewhat 
unusual,  and  asked  his  permission  to  keep  the  patient 
under  observation  for  ten  days  in  order  to  make  a 
further  examination,  to  which  he  willingly  agreed. 

I  could  then  examine  the  patient  at  leisure.  The 
heart  presented  no  appreciable  change,  though  the 
pulse  was  slow.  The  kidney  region  was  painless  on 
palpation  so  far  as  it  was  possible  to  examine  it,  for 
Mme.  X.,  while  not  obese,  was  short  and  stout,  weighing 
204  lb.  Her  lower  limbs  did  not  appear  notably  swol- 
len and  though  large  were  not  out  of  proportion  to  her 


46 


body.  Her  temperature  was  rather  low  and  she  com- 
plained of  cold  although  it  was  the  end  of  May  and  a 
large  fire  made  the  room  uncomfortably  warm.  The 
patient  told  me  that  she  always  felt  the  cold  most  in- 
tensely about  4  o'clock  in  the  afternoon,  at  which  time 
she  felt  as  if  cold  water  had  been  poured  on  her  back, 
causing  her  actually  to  shiver.  She  soon  became  tired 
during  my  examination  and  even  fell  asleep  while  I 
talked  to  her,  complaining  of  extreme  lassitude  and 
rheumatic  pains  throughout  the  whole  of  her  body. 

Having  discovered  all  this  I  had  advanced  no  further 
than  before.     That  a  woman  64  years  of  age  should  be 


■*#*" 


Fig.  14. — Same  patient  as  in  Fig.  13  after  treatment. 

sleepy,  chilly,  easily  tired  and  suffer  from  rheumatism 
was  neither  very  extraordinary  nor  was  it  pathog- 
nomonic. Five  days  had  passed,  when  chance, — the 
Providence  of  doctors, — came  to  my  assistance.  M.  X. 
informed  me  that  he  was  expecting  an  early  visit  from 
his  wife's  cousin  who  suffered  from  a  very  troublesome 
goiter  which  at  times  threatened  to  suffocate  her.  He 
also  told  me  that  I  might  be  consulted  by  her  and, 
should  alarming  symptoms  occur,  I  might  even  be 
asked  to  remove  the  tumor.  Now  goiter  is  a  rarity  in 
Antwerp  and  for  my  part  I  had  never  seen  a  single 
case  and  was  rather  worried  at  the  prospect. 

My  situation  was  truly  awkward,  the  old  lady  ap- 
parently had  Bright's  disease  but  without  albuminuria 
and  seemed  to  be  at  the  point  of  death  without  present- 
ing a  single  positive  symptom  which  I  could  lay  hold 
of; — and  then  this  cousin  must  needs  come  from  the 
other   end   of   Austria   possessed   by   the   desire   to   be 


47 


Fio.  15. — Severe  myxedema. 

operated  upon  for  a  tumor  which  she  would  a  hundred 
times  better  have  had  removed  in  her  own  country, 
where  they  are  accustomed  to  similar  exploits. 

I  returned  home  in  a  state  of  great  anxiety  and  felt 
a  real  relief  on  finding  on  my  table  a  large  parcel  con- 
taining the  treatise  on  surgery  in  8  volumes  by  Duplay 
and  Reclus  which  had  just  been  published.  I  turned 
to  the  article  on  goiter  by  Broca.  Oh,  yes !  goiter  could 
certainly  be  removed:     it  was  not  easy,  but  with  de- 


Fig.  16. — Same  patient  as  in  Fig.  15  after  treatment. 
48 


Fig.  17. — Severe  myxedema,  before  and  after  treatment. 

termination  and  a  score  of  artery  forceps  it  could  be 
done.  Then  there  were  complications — one  must  not 
divide  the  recurrent  laryngeal — must  guard  against 
hemorrhage  and  sepsis.  And  this  was  not  all, — one 
must  beware  of  removing  the  whole  of  the  thyroid 
gland — for  this  was  followed  after  a  short  interval  by 
a  special  cachexia  which  Kocher  had  named  "Cachexia 
strumipriva"  and  Reverdin  had  called  "Post-operative 
myxedema."  This  was  becoming  more  and  more  in- 
teresting. 

Thus  when  the  patient  had  escaped  from  the  dangers 
of  the  operation,  hemorrhage,  and  sepsis,  just  when 
we  might  expect  him  to  enter  upon  convalescence,  a 
very  strange  condition  gradually  disclosed  itself,  char- 
acterized by  the  following  symptoms: — lassitude, 
feebleness,  clumsiness,  heaviness  of  the  limbs,  pain  in 
the   arms,   legs,  neck,   and  shoulders,   swelling   of   the 


Fio.  18. — Profile  view  of  the  same  patient  shown  in  Fig.  17. 

49 


face  and  puffiness  of  the  eyelids.  The  eyes  become 
sunken,  the  activity  of  the  brain  diminished  and  men- 
tal effort  dulled.  Then  there  came  an  extraordinary 
phase:  "The  urine  is  almost  always  normal,  to  the 
astonishment  of  the  early  observers  who  expected  from 
the  appearance  of  the  face  to  discover  albumin.  And 
again  another  phrase: — one  of  the  most  remarkable 
phenomena  is  a  sensation  of  cold,  which  is  almost  con- 
stant. 

Truly  Mme.  X.  presented  a  complete  picture  of  these 


Fig.  19. — Severe  myxedema  with  predominance  of  rheumatoid 
pains  before  treatment. 

symptoms.  She  had  the  false  suggestion  of  albumin- 
uria without  the  presence  of  albumin,  and  the  general 
swelling  of  the  body.  Like  the  patients  operated  upon 
by  Kocher,  Reverdin,  and  Bruns,  she  had  the  drawling 
voice,  the  sluggish  attitude  of  body,  the  thinned  hair 
and  eyebrows,  the  swollen  mucous  membranes,  and  the 
difficulty  in  swallowing.  Her  tongue  appeared  too 
large  for  her  mouth,  the  floor  of  which  was  swollen 
and  raised  till  it  suggested  a  double  ranula.  Even  her 
ocular  conjunctiva  was  edematous  and  prolapsed  while 
her  complexion  was  amber-yellow  with  patches  of  red 
on  the  cheeks.     She  had  also  the  low  temperature  with 


50 


subjective  sensations  of  cold — but  indeed  Mme.  X. 
presented  all  the  symptoms  described  in  post-operative 
myxedema  and  if  so  she  must  suffer  from  spontaneous 
myxedema. 

At  last  my  diagnosis  was  made.  On  the  following 
day  I  verified  the  presence  of  the  hard,  nondepressible 
edema  extending  over  the  whole  body  and  some  other 
symptoms  which  I  had  not  previously  recognized.  I 
then  informed  her  husband  of  what  I  had  discovered 
and   that   I   was   prepared   to   commence   treatment   at 


Fig.  20. — Same  patient  as  shown  in  Fig.  19,  after  treatment. 

once.  M.  X.  was  too  polite  to  say  that  he  did  not  be- 
lieve me,  though  his  face  plainly  showed  his  incre- 
dulity, but  he  followed  my  instructions  to  the  letter. 

The  result  exceeded  my  hopes.  After  three  weeks 
treatment  the  bodily  and  mental  transformation  was 
so  complete  that  she  would  no  longer  have  been  recog- 
nized as  the  same  woman  (Fig.  5).  The  edema  of  the 
tongue,  of  the  lips,  and  of  the  eyelids  disappeared  as 
if  by  enchantment  and  the  face  assumed  an  intelligent 
expression.  The  patient  then  went  to  the  country 
where  the  treatment  was  continued  by  the  local  doctor, 
who  gave  me  valuable  assistance.     I  did  not  see  her 


61 


Fig. 


21. — Severe    myxedema,    cachectic    stage,    three    days 
before  death. 


again  for  over  two  months  by  which  time  she  had 
completely  recovered,  that  is  to  say  the  absorption 
of  the  infiltration  had  been  complete. 

If  you  now  ask  me  what  we  have  to  learn  from 
this  observation  as  regards  mild  myxedema,  and 
on  what  point  it  helps  our  knowledge  of  this  con- 
dition, I  would  first  direct  your  attention  to  the 
metrorrhagia  which  is  presented  by  the  history  of 
the  patient.  As  a  rule  thyroid  weakness  shows 
itself  by  the  presence  of  metrorrhagia  which  is 
sometimes  appalling  in  its  amount.  The  adminis- 
tration of  thyroidin  moderates  these  losses,  and 
if  large  doses  are  given  one  may  even  completely 


52 


suppress  menstruation,  as  in  the  same  way  com- 
plete amenorrhea  is  not  infrequently  present  in 
cases  of  exophthalmic  goiter.  Women  with  feeble 
thyroids  conceive  readily,  but  abort  as  readily  in 
consequence  of  the  onset  of  profuse  bleeding  which 
carries  away  the  fertilized  ovum.  I  do  not  mean 
to  say  that  a  woman  suffering  from  thyroid  weak- 
ness cannot  go  to  full  term,  as  from  the  beginning 
of  pregnancy  the  thyroid  gland  undergoes  hyper- 
trophy with  increase  in  size  and  in  the  amount  of 
its  secretion.  In  fortunate  cases  this  increased 
activity  is  maintained  throughout  pregnancy  and 
forms  an  effectual  protection  to  the  embryo  against 
the  menstrual  return.  Such  women  tell  you  that 
their  health  is  better  when  pregnant.  The  in- 
creased activity  of  the  gland  continues  during  lac- 
tation, and  such  patients  instinctively  prolong  suck- 
ling beyond  the  physiological  period.  After  wean- 
ing, the  symptoms  of  thyroid  weakness  reappear 
and  certain  authors  have  even  discovered  in  pro- 
longed lactation  a  cause  of  myxedema.  Thus  when 
you  encounter  cases  of  profuse  menstruation  in 
which  you  can  exclude  such  ordinary  causes  as 
fibroids,  cancer,  or  placental  remains,  think  of  pos- 
sible thyroid  defect  and  search  for  other  symptoms 
of  this  condition. 

Think  of  it  also  in  those  disheartening  cases  of 
repeated  abortion,  in  which  the  administration  of 
thyroidin  will  often  permit  a  pregnancy  to  go  to 
term  when  all  other  rational  means  of  treatment 
have  failed. 

I  would  in  the  second  place  direct  your  attention 
to  the  rheumatic  pains  from  which  this  patient 
suffered.  In  almost  all  cases  of  severe  myxedema 
one  finds  that  the  patient  at  some  period  of  life 
has  passed  through  an  attack  of  acute  articular 
rheumatism.  This  affection  can  itself  cause  grave 
disturbances  of  the  thyroid  gland,  the  congestion  of 
which  in  the  course  of  acute  articular  rheumatism 
is  a  classic  symptom.  I  believe,  however,  that  its 
influence  is  usually  limited  to  producing  an  aggrava- 
tion of  a  pre-existing  thyroid  weakness,  thus  bring- 
ing to  light  symptoms  hitherto  unnoticed.  The 
metrorrhagia  from  which  Mme.  X.  had  suffered 
before  the  occurrence  of  her  acute  rheumatic  attack 
supports  this  view.  The  chronic  rheumatic  or 
rheumatoid  condition  is  almost  always  associated 
with  mild  myxedema,  and  its  occurrence  should  be 
carefully  inquired  into,  especially  when  met- 
rorrhagia is  also  present.     These  pains,  which  are 

53 


often  complicated  by  neuralgia,  tend  to  assume  a 
characteristic  form  and  course,  to  which  I  will  now 
refer.  The  most  frequent  rheumatoid  pain  ex- 
perienced in  mild  myxedema  is  that  affecting  the 
back  between  the  shoulder  blades,  and  is  most 
severe  in  the  morning  on  rising,  after  the  chilling 
and  inanition  of  the  night.  Driven  from  bed  by  the 
pain,  these  patients  rise  absolutely  worn  out,  as  if 
they  had  slept  on  a  hard  uneven  mattress.  The 
pains  subside  gradually  during  the  day,  owing  to 
the  warmth  produced  by  food  and  exercise,  and  dis- 
appear completely  in  the  evening  after  a  good  meal 
with  plenty  of  wine.  Such  patients  are  strongly 
attracted  to  the  use  of  alcoholic  stimulants. 

I  have  already  stated  my  opinion  as  to  the  low- 
ered temperature  and  the  subjective  feeling  of  cold, 
so  I  need  not  insist  further  on  this  point.  The 
hard,  cold  hand  of  a  patient  suffering  from  severe 
myxedema  is  very  characteristic,  and  in  the  milder 
forms  coldness  of  the  extremities  is  usually  present, 
though  to  a  less  degree,  as  I  have  already  stated. 

Among  the  symptoms  presented  by  Mme.  X.,  one 
of  the  more  interesting  was  the  special  character 
of  the  voice  and  speech.  The  voice  was  deep,  rough, 
and  croaking,  with  an  indescribable  quality  which 
when  once  heard  could  not  be  forgotten.  This 
symptom  is  caused  by  the  infiltration  of  the  vocal 
chords  and  the  pharyngeal  mucous  membrane,  and 
is  present  in  a  less  marked  degree  in  milder  forms 
of  hypothyroidism.  In  women  with  feeble  thyroids 
the  voice  is  slightly  hollow  or  muffled.  Sometimes 
this  is  only  occasionally  present,  as  during  men- 
struation, when  a  considerable  part  of  the  thyroid 
resources  is  employed  in  the  inhibition  of  the  men- 
strual function.  We  will  not  consider  further  the 
case  of  Mme.  X.,  though  interesting  from  the  stand- 
point of  our  subject,  but  will  bear  in  mind  as  lead- 
ing symptoms  the  metrorrhagia,  the  recurring  abor- 
tions, the  rheumatoid  pains,  the  feeling  of  chilliness, 
and  the  alteration  of  the  voice. 

After  my  attendance  on  Mme.  X.,  I  reproached 
myself  for  having  so  long  neglected  to  inform  myself 
as  to  the  diseased  conditions  of  the  thyroid  gland. 
During  my  ten  years  of  practice  I  must  have  already 
met  with  these  cases  of  apparent  Bright's  disease; 
I  had  treated  them,  and  they  had  disappeared  and 
been  forgotten.  Surely  I  had  heard  somewhere  a 
voice  similar  to  that  of  Mme.  X.,  but  when?  and 
where?  On  racking  my  brains,  I  remembered  that 
one  day  I  had  been  summoned  as  an  expert  before 

54 


Fig.  22. — Myxedema,  severe  form,  before  and  after  treatment. 


55 


the  Civil  Pensions  Commission,  the  administrative 
body  to  which  the  servants  of  the  State  apply  when 
on  account  of  infirmity  they  wish  to  claim  their  pen- 
sion before  the  retiring  age  or  when  it  is  necessary 
to  retire  them.  It  decides  in  accordance  with  the 
advice  of  the  medical  experts. 

A  professor  of  solfeggio  in  the  Antwerp  Conserva- 
toire had  appeared  before  us.  His  condition  was  so 
lamentable,  so  profoundly  cachectic,  that  my  colleague 
and  I  requested  the  President  to  send  some  one  home 
with  him  lest  he  should  fall  in  the  street.  The  strange, 
hoarse,  croaking  voice  of  this  man  whose  occupation 
was  the  teaching  of  singing  to  children,  was  so  irresist- 
ibly comic  that  commissioners  and  doctors  alike  had 
great  difficulty  in  keeping  their  gravity.  The  medical 
examination  did  not  take  long  and  the  verdict  was 
explicit — Bright's  disease  in  its  last  stage  with  uremia, 
and  he  was  at  once  retired  on  pension. 

I  searched  for  and  found  the  singing  master  who 
was  still  alive,  and  whom  I  now  recognized  to  be  suffer- 
ing from  myxedema.  I  show  here  his  photograph  be- 
fore and  after  treatment  (Fig.  6).  I  informed  the 
Minister  of  the  error,  who  sharply  rebuked  the  Com- 
mission for  a  mistake  made  through  no  fault  of  theirs. 
The  board  then  had  the  patient  examined  afresh  by 
other  doctors,  who  discovered  nothing  wrong  with  him 
as  he  no  longer  presented  the  least  sign  of  myxedema. 
The  proposal  to  retire  him  was  withdrawn,  and  his 
voice  having  now  recovered,  he  was  able  to  resume  his 
class  with  a  brilliancy  to  which  he  had  been  long  a 
stranger.  He  was  at  this  time  55  years  of  age.  Before 
treatment  was  begun  his  whole  face  was  swollen,  espe- 
cially the  eyelids,  the  space  between  which  was  reduced 
to  a  mere  slit.  He  also  suffered  from  rheumatic  pains, 
a  constant  feeling  of  cold,  and  continual  dyspnea.  The 
skin  was  dry,  thin,  and  scaly,  the  epidermis  covered 
with  fine  lozenge-shaped  wrinkles.  The  whole  body 
was  heavy,  clumsy,  and  infiltrated  with  a  firm  resistant 
edema.  He  complained  of  invincible  somnolence,  de- 
pression, and  weariness  of  life.  The  infiltration  was 
rapidly  absorbed  under  treatment,  his  weight  falling 
from  169  lb.  to  136  lb.  in  two  months,  at  the  end  of 
which  period  the  second  photograph  was  taken. 

Here  for  the  first  time  dyspnea  appears  as  a 
leading  symptom  of  myxedema.  The  patient  had 
suffered  from  it  for  a  long  time,  and  in  my  former 
notes  of  his  condition  I  found  it  occupied  an  im- 
portant place.  His  walk  was  slow  and  difficult,  and 
he  required  to  support  himself  by  the  furniture, 
making  signs  that  he  could  not  speak  for  want  of 
breath.  In  mild  myxedema  this  breathlessness  is 
constantly  present,  though  to  a  less  degree,  only 
showing  itself  on  walking  rapidly  or  uphill,  and  is 
usually  accompanied  by  palpitation.  Sometimes  the 
breathlessness  is  intermittent,  like  the  insufficiency 
of  the  thyroid  secretion  on  which  it  depends,  and  is 
then  liable  to  be  mistaken  for  an  attack  of  asthma. 

56 


The  gratitude  of  this  singing  master  was  all  the 
greater  that  he  had  been  restored  to  his  duties  and 
escaped  the  misery  of  a  premature  pension.  He 
told  me  that  one  of  his  friends,  a  police  agent,  who 
had  been  put  upon  the  retired  list  ten  years  before, 
suffered  from  the  same  condition  as  himself.  This 
was  rather  too  much — to  have  myxedema  diagnosed 
by  a  patient  who  had  only  just  recovered  from  the 
disease. 

I  called  on  the  police  agent  whose  appearance  be- 
fore and  after  treatment  is  shown  in  the  photographs 
(Fig.  7).  He  was  suffering  from  very  advanced  myxe- 
dema and  though  only  42  he  appeared  much  older.  The 
photograph  shows  the  degree  of  cachexia  at  which  he 
had  arrived.     His  whole  face  was  infiltrated,  the  eye- 


Fig.    23. — The    patient    shown    in    Fig.    2    after    14    years    of 
treatment. 

lids  being  so  swollen  that  the  eyes  could  be  opened 
only  with  the  greatest  difficulty,  while  the  thickened 
lips  resembled  those  of  a  negro.  The  complexion  was 
amber  yellow  with  bright  red  patches  on  the  cheeks. 
The  trophic  changes  in  the  hair  were  striking,  the  fore- 
head presented  a  band  of  brown  pigmentation  and 
there  were  similar  marks  on  each  side  of  the  neck.  The 
head  was  too  heavy  for  the  infiltrated  muscles  and 
ligaments  of  the  neck  so  that  it  fell  forward  and  the 
patient  could  raise  it  only  by  throwing  the  trunk  back- 
wards. He  complained  of  rheumatism  and  a  perpetual 
feeling  of  cold,  huddling  himself  night  and  day  under 
thick  bedclothes.  The  breath  was  offensive,  the  teeth 
bad,  the  gums  red  and  inflamed.  Speech  was  much 
impaired.  On  replying  to  a  question  he  opened  his 
mouth  widely,  so  that  the  motions  of  his  tongue  could 
be  plainly  seen  although  he  uttered  no  sound,  and  it 
was  only  after  a  lengthy  effort  that  the  words  were 
slowly  formed.     His  weight  was  152  lb.  of  which  he 

57 


lost  22  lb.  under  treatment  with  the  simultaneous  im- 
provement of  all  his  symptoms.  The  loss  of  weight 
in  this  case  amounted  to  18,  28,  and  even  35  ounces  a 
day.  His  hair  grew  again  rapidly,  muscular  con- 
tractility was  regained  so  that  he  could  again  raise 
his  head,  and  he  was  delighted  to  find  his  self-con- 
fidence return,  complete  recovery  being  attained  in 
about  two  months. 

This  case  directs  our  attention  to  the  trophic 
changes  of  the  hair,  teeth,  and  gums.  In  the  milder 
type  of  myxedema  the  hair  may  also  be  shed  early, 
though  more  frequently  it  becomes  prematurely 
grey.  The  destruction  of  the  teeth  and  the  chronic 
alteration  of  the  gums  is  also  observed,  though  to  a 
less  extent. 


Fig.  24. — Mild  myxedema  in  the  mother  of  the  patient  pictured 
in  Figs.  2  and  23. 

Whatever  the  type  of  myxedema,  the  baldness 
very  constantly  presents  a  special  distribution,  the 
hair  being  first  shed  in  the  frontal  region,  then  on 
the  nape  of  the  neck,  giving  the  appearance  which 
is  well  shown  in  Figs  8  and  9.  The  loss  of  the  hair 
in  the  eyebrows  is  early  and  constant,  even  in  mild 
myxedema,  and  has  been  called  the  eyebrow  sign. 
It  is  not  so  easily  concealed  as  the  baldness  of  the 
scalp,  and  it  gives  to  the  patient's  face  an  air  of 
perpetual  astonishment. 

Fig.  10  is  the  portrait  of  a  woman  aged  24  who  had 
suffered  from  uterine  hemorrhage  since  her  confine- 
ment, four  months  previously,  for  which  she  had  been 
packed  and  curetted  several  times.  The  absence  of 
the  eyebrows  is  striking,  and  though  the  frontal  bald- 
ness had  been  artfully  concealed,  she  at  once  suggested 
to   me   a    case   of   insufficient   thyroid    secretion.      She 

58 


suffered  much  from  migraine  and  also  from  occipital 
headaches;  she  was  always  cold,  while  her  menses 
were  always  very  profuse.  Under  thyroid  treatment 
the  hemorrhage  ceased  in  a  fortnight. 

A  very  interesting  case  of  myxedema  is  shown  in 
figures  11  and  12.  There  was  marked  loss  of  hair 
which  in  addition  to  the  usual  situations  had  affected 
the  sagittal  line,  but  the  baldness  was  concealed  by  the 
presence  of  black  crusts  which  covered  the  whole  scalp, 
the  eyebrows  were  also  markedly  affected.  This  pa- 
tient might  be  classed  as  an  advanced  case  of  myxe- 
dema and  the  result  of  treatment  was  very  striking. 
She  had  always  been  tired,  constipated,  and  somnolent. 
She  was  never  free  from  rheumatic  pains  and  became 
breathless  on  the  slighest  exertion.  Her  face  was  in- 
filtrated, the  eyelids  and  lips  being  specially  swollen. 
Under  thyroid  extract  she  rapidly  lost  22  lb.  in  weight 
and  after  four  months  treatment,  was  completely 
changed  both  morally  and  physically,  having  regained 


Fig.   25. — Mild  myxedema,  before  and  after  treatment. 

courage,  strength,  and  cheerfulness.  She  even  became 
coquettish  and  would  not  believe  that  her  appearance 
had  been  as  in  the  first  photograph. 

The  patient  shown  in  Figs.  13  and  14  is  a  good 
example  of  the  effects  of  thyroid  weakness  on  the 
hair  and  eyebrows.  She  was  only  39  years  of  age,  but 
appeared  much  older.  The  face  was  swollen,  amber 
yellow  in  color,  with  patches  of  red  on  the  cheeks. 
The  trophic  changes  had  chiefly  affected  the  hair  and 
teeth,  the  nape  of  the  neck  being  almost  bald.  She 
complained  of  a  constant  sensation  of  cold,  obstinate 
constipation,  and  pains  all  over  the  body,  which  she 
attributed  to  rheumatism.  She  presented  also  the 
drawling  voice  with  its  characteristic  intonation.  Her 
weight  was  154  lb.,  of  which  she  lost  22  lb.  in  the 
course  of  treatment. 

The  patient  presented  in  Figs.  15  and  16  was  42 
years  of  age.  Fourteen  years  before,  as  the  result 
of  a  chill,  she  suffered  from  swelling  of  the  hands  and 
feet  with  albuminuria.  She  was  treated  for  Bright's 
disease,  but  did  not  recover  her  health,  dragging  on  in 
a  weak,  exhausted,  somnolent  condition,  with  pains  in 
all   her   limbs.     Becoming  pregnant  she   suddenly  im- 


59 


proved  considerably,  due  to  the  stimulation  of  the 
thyroid  gland  by  her  condition.  This  improvement 
lasted  throughout  pregnancy  and  was  maintained  dur- 
ing lactation,  although  she  nursed  her  infant  for  two 
years.  After  weaning  him  she  gradually  relapsed  into 
her  previous  condition,  again  becoming  apathetic  and 
depressed  while  the  rheumatic  pains  returned  with  in- 
creased severity.  The  eyebrows  were  very  thin,  the 
features  swollen,  while  the  pale  yellow  complexion 
recalled  that  usually  associated  with  albuminuria.  She 
suffered  from  constipation  and  headache,  her  teeth 
were  decayed,  and  she  presented  attacks  of  shivering 
during   the   evening   which    were    attributed   to   fever. 


Pig.  26. — Severe  myxedema  before  treatment 

All    these    symptoms    improved    under    treatment,    her 
weight  at  the  same  time  falling  from  143  to  138  lb. 

The  patient  shown  in  Figs.  17  and  18  was  only  39 
years  of  age.  He  was  a  cigar  maker,  who  had  been 
unable  to  work  for  six  years,  owing  to  his  fingers 
haying  become  stiff  and  clumsy.  He  had  taken  to 
drink  and  he  and  his  family  had  fallen  into  extreme 
poverty.  He  was  positively  ugly,  and  the  boys  of  the 
district,  who  knew  him  under  the  name  of  Ravachol, 
followed  him  on  the  street.  I  literally  picked  him  out 
of  the  gutter  and  kept  him  under  observation  for  a 
week  before  commencing  treatment.  His  appearance 
is  well  shown  in  the  illustrations.  He  complained  of 
pain  in  the  spine,  a  constant  feeling  of  cold  and  in- 
superable fatigue,  and  was  melancholic,  depressed,  and 
extremely  miserable.     His  hair  was  unaffected,  except 

60 


in  the  occipital  region,  which  was  bald.  During  the 
week  before  treatment  was  commenced  he  excreted  on 
an  average  323.4  grains  of  urea  per  day,  which  in- 
creased under  thyroidin  to  an  average  of  477.4  grains 
per  day,  during  the  first  week,  with  a  further  increase 
during  the  second  week  to  677.6  grains  per  day.  In 
consequence  of  the  absorption  of  the  infiltration  his 
weight  fell  from  167  lb.  to  138  lb.  His  urine  contained 
an  extraordinary  number  of  spermatozoa,  this  symp- 
tom persisting  for  a  whole  month,  when  it  suddenly 
ceased.  He  rapidly  recovered  as  shown  by  the  illus- 
tration, and  he  not  only  regained  his  health  but  also  his 
self-confidence,  so  that  he  resumed  his  work,  at  which 


Fig.  27. — The  same  patient  as  in  Pig.  26,  after  two  months* 
treatment. 

he  was  expert,  and  after  some  months  sailed  for  Amer- 
ica in  quest  of  a  better  situation.  He  obtained  work 
at  once,  and  is  now  himself  an  employer,  and  has  made 
money.  Every  two  or  three  years  he  returns  to  Europe 
to  express  his  gratitude  to  me. 

Soon  after  the  cure  of  the  singing  master  and  the 
police  agent  I  remembered  that  at  the  beginning  of 
my  career  I  had  treated  a  woman  of  whose  peculiar 
voice  I  was  reminded  by  that  of  these  two  patients. 
She  had  left  town,  but  at  last  I  discovered  her.  In 
those  days  she  had  suffered  from  rheumatism  in- 
volving all  the  body,  the  muscles  being  stiff,  hard, 
and  painful.    The  joints  were  also  swollen,  the  gait 

61 


stiff  and  awkward,  while  the  pains  in  the  back  were 
very  severe.  I  had  formerly  treated  her  by  every 
means  I  could  think  of,  without  benefit.  On  her 
reappearance  I  found  that  she  was  really  suffering 
from  myxedema — as  you  will  see  by  the  photographs 
before  and  after  treatment  (Figs.  19  and  20).  The 
puffiness  of  the  face,  the  swelling  of  the  lips,  espe- 
cially the  lower  one,  the  loss  of  the  hair  of  the 
scalp  and  eyebrows,  the  redness  of  the  cheeks  on  a 
yellow  skin,  the  drawling,  croaking  voice,  the  dry 
wrinkled  skin,  and  the  desquamation  of  the  scalp 


Fig.   28. — Severe  myxedema. 

left  no  doubt  as  to  the  diagnosis.  Under  thyroid 
treatment  the  infiltration  rapidly  disappeared.  The 
general  pain  and  stiffness  also  disappeared  steadily, 
though  slowly,  along  with  marked  breathlessness, 
to  which  she  had  always  been  subject,  and  which  I 
had  formerly  attributed  partly  to  obesity  and  partly 
to  pulmonary  emphysema.  Finally  all  these  symp- 
toms were  completely  abolished,  but  on  the  patient 
ceasing  treatment  the  pains  gradually  returned,  to 
cease  again  on  the  administration  of  thyroidin. 
This  woman  had  suffered  from  these  rheumatic 
symptoms  for  so  many  years  that  she  had  become 
resigned  to  them,  and  sought  advice  only  when  the 


62 


pain  in  the  back  or  the  swelling  in  the  wrists  or 
knees  became  unusually  severe.  The  pain  was  then, 
as  later,  simply  a  manifestation  of  defective  thyroid 
secretion. 

Let  me  now  record  a  case  illustrating  the  dis- 
orders of  the  liver  associated  with  defect  in  the 
thyroid  gland.  The  patient  shown  in  Fig.  21  was 
a  women  suffering  from  myxedema  in  its  last  stage. 
She  died  three  days  after  admission  to  my  ward 
without  it  being  possible  to  begin  thyroid  treatment. 
On  post-mortem  examination  the  gall-bladder  was 


Fig.  29. — The  same  patient  as  in  Fig.  28,  after  treatment. 

found  much  enlarged,  distended  to  the  bursting 
point,  with  marked  thinning  at  its  upper  pole.  It 
contained  a  large  gallstone,  which  permitted  the  en- 
trance but  not  the  escape  of  the  bile.  I  was  much 
impressed  by  this  observation,  and  later  in  cases  of 
myxedema,  whether  mild  or  severe,  I  examined  for 
tenderness  of  the  liver  and  especially  of  the  gall- 
bladder. Very  frequently,  not  to  say  always,  a  pain- 
ful point  was  found  in  this  region,  which  disap- 
peared during  treatment.  Although  the  presence  of 
a  calculus  in  the  gall-bladder  is  a  common  occur- 
rence in  the  post-mortem  room,  I  have  dwelt  on  it 
and  shown  this  photograph  in  order  to  emphasize 

63 


the  frequent  presence  of  disorders  of  the  liver  in 
myxedema,  of  whatever  type.  In  this  affection  one 
should  always  think  of  congestion  of  the  liver  and 
the  possible  presence  of  calculi  or  biliary  sand  in 
the  gall-bladder.  The  amber  yellow  coloration  of 
the  skin,  so  characteristic  of  myxedema,  is  only  an 
attenuated  jaundice  and  depends  on  biliary  dis- 
turbances. 

Fig.  22  is  that  of  a  woman  40  years  of  age, 
suffering  from  well-marked  myxedema.  Her  father, 
who  was  dead,  had  suffered  from  rheumatism  and  al- 


Pig.   30. — Mild  myxedema  with  atrophy  of  the  optic  nerves. 

buminuria.  She  had  six  children;  the  eldest  daughter 
was  subject  to  metrorrhagia,  while  two  of  the  sons  had 
suffered  very  severely  from  acute  articular  rheuma- 
tism. Her  appetite  had  completely  gone,  she  suffered 
from  menorrhagia,  with  headaches  and  frequent  at- 
tacks of  shivering.  Her  temperature  taken  in  the 
mouth  was  only  96.2°  F.  There  was  great  swelling 
of  the  face,  but  the  hair  was  well  preserved  and  the 
teeth  in  good  condition.  She  suffered  from  melan- 
cholia and  apathy  with  difficulty  of  thought,  speech,  and 
action.  After  six  weeks'  treatment  at  the  Institute 
she  was  discharged  so  changed  in  appearance  that  she 
would  not  have  been  recognized.  Since  then  she  had 
continued  her  treatment,  but  only  very  irregularly. 
When  she  neglected  it  too  long  the  first  symptoms  of 
relapse  were  a  feeling  of  weight  at  the  stomach,  diffi- 

64 


culty  in  stooping,  tenderness  over  the  liver,  and  a 
distaste  for  meat.  After  an  unusually  long  period 
of  neglected  treatment  she  sent  for  me  in  haste  one 
night  and  was  found  suffering  from  biliary  colic.  The 
urgent  symptoms  yielded  to  oil  and  morphine  and  later 
under  thyroidin  she  made  a  complete  recovery. 

I  have  said  that  an  excellent  means  of  becoming 
acquainted  with  the  slighter  degrees  of  myxedema 
is  to  study  the  morbid  characteristics  of  the  ascend- 
ing, descending,  or  collateral  relations  of  patients 
suffering  from  the  more  severe  type,  the  weakness 
of  the  thyroid  gland  being  essentially  hereditary. 


Fig.   31. — Same  patient  as  in  Fig.   30,  after  treatment. 

I  have  shown  in  Fig.  2  four  photographs  of  a  child 
who  suffered  from  severe  myxedema,  and  presented 
marked  delay  in  her  physical  and  intellectual  de- 
velopment. When  first  brought  to  me  in  November, 
1896,  she  was  8  years  of  age,  and  she  measured 
only  2  ft.  10  in.  in  height,  instead  of  3  ft.  10  in., 
the  normal  average  for  her  age,  though  she  was 
comparatively  heavy,  her  weight  being  33  pounds. 
The  expression  of  the  face  was  that  of  well-marked 
myxedema;  the  face  itself  was  swollen  with  the 
characteristic  red  cheeks  on  an  amber  yellow  skin. 
The  dystrophy  had  not  involved  all  the  tissues  to 
the  same  extent,  those  of  epidermic  origin  being 
relatively  intact.    The  hair  was  black  and  thick,  the 

65 


eyebrows  were  well  marked,  while  the  teeth  were 
healthy,  an  exceptional  event  in  myxedema.  The 
bones,  on  the  other  hand,  were  severely  affected, 
the  femora  were  curved,  the  tibiae  and  fibula?  showed 
advanced  signs  of  rickets,  and  the  feet  were  short 
and  flat.  The  belly  was  large — a  characteristic  of 
this  affection — and  presented  an  umbilical  hernia. 
The  false  ribs  had  been  carried  outwards  by  the 
distention  of  the  abdomen — a  change  more  apparent 
in  the  second  photograph,  where  the  belly  has  been 


Fig.  32. — M.  A.,  severe  myxedema  ;  before  treatment. 

reduced  by  a  year's  treatment.  Her  intelligence  was 
but  slightly  developed.  Her  temperature  was  very 
low,  even  in  summer,  and  in  winter  it  became  ex- 
tremely so,  there  being  great  difficulty  in  keeping 
her  warm.  She  throve  badly,  and  was  extremely 
constipated.  There  could  be  no  doubt  as  to  the 
cause  of  the  condition — a  congenital  weakness  of 
the  thyroid  gland. 

The  patient's  mother  had  suffered  from  several 
severe  attacks  of  malarial  fever  in  the  course  of  her 
pregnancy,  and  had  been  obliged  to  leave  the  low- 
lying  village  where  she  lived  and  come  into  town 
for  her  confinement.  Four  years  previously,  before 
she  lived  in  this  low-lying  district,  she  had  borne  a 


G6 


son,  now  12  years  of  age,  who  was  slender  and 
delicate.  A  second  child  had  died  of  some  abdominal 
condition  at  the  age  of  five  months,  the  third  being 
the  patient  with  whom  we  are  now  concerned. 
I  have  often  observed  that  for  the  production  of 
a  severe  case  of  congenital  myxedema  the  associa- 
tion of  at  least  two  grave  defects  in  the  parents  is 
necessary,  as,  for  example,  the  coexistence  of 
syphilis  and  tuberculosis;  gout  or  diabetes,  com- 
plicated with  tuberculosis  or  syphilis ;  or,  again,  the 


Fig.  33. — M.  A.  after  two  months'  treatment 

coincidence  of  alcoholism  and  syphilis.  The  mother 
was  therefore  carefully  examined  to  discover  the 
defect  which,  joined  to  malaria,  had  produced  such 
a  complete  degeneration  in  the  fetus.  She  suffered 
from  severe  migraine,  was  very  constipated,  her 
liver  and  gall-bladder  were  tender,  and  her  men- 
strual loss  was  excessive.  She  also  complained  of 
transient  rheumatoid  pains  in  her  muscles,  which 
became  aggravated  during  the  cold  season.  She  was 
dull,  depressed,  almost  melancholic,  and  presented  a 
low  temperature,  frequent  breathlessness  and  pal- 
pitation. Her  complexion  was  pale  yellow,  like  that 
of  the  child.  Vertigo,  tinnitus,  and  muscae  volitantes 
were  also  present. 

G7 


The  clinical  picture  was  that  of  the  simpler  forms 
of  thyroid  defect.  Without  being  myxedematous 
she  evidently  suffered  from  thyroid  weakness.  The 
malarial  poison  had  done  the  rest,  and  the  mother, 
unable  to  furnish  the  fetus  with  the  necessary 
amount  of  thyroid  secretion,  gave  birth  to  a  cretin. 

The  little  patient  quickly  responded  to  treatment 
by  thyroidin.  After  a  year  her  appearance  had 
much  improved,  as  seen  in  the  second  photograph 
(Fig.  26).  At  the  beginning  of  treatment  the 
thyroid    extract    appeared    to    disagree    with    the 


lrio.  34. — M.   A.  after  14  months'  treatment. 

patient,  causing  vomiting  in  the  morning,  before 
breakfast,  but  in  spite  of  this  its  administration 
was  continued.  During  the  first  year  she  gained 
5V2  inches  in  height,  while  the  rachitic  deformities 
greatly  improved  but  did  not  entirely  disappear. 
The  distended  abdomen  assumed  more  natural  pro- 
portions, the  umbilical  ring  closed,  and  the  neck 
became  more  slender.  The  expression  of  her  face 
became  more  inquiring  and  thoughtful.  Her  prog- 
ress during  the  second  year  was  less  satisfactory, 
as  she  unfortunately  suffered  severely  from  whoop- 
ing-cough, which  lasted  five  months.  The  increase 
in  height  amounted  to  only  2*4  in.,  but  all  traces 

68 


of  rickets  had  disappeared  from  the  limbs.  The 
third  photograph  (c)  shows  her  appearance  at  the 
end  of  the  second  year. 

The  action  of  infectious  diseases  on  the  activity 
of  the  thyroid  gland  has  been  well  known  since  the 
work  of  Marcel  Gamier.5  He  states  in  connection 
with  a  case  of  whooping-cough  which  proved  fatal 
by  bronchopneumonia:  "The  thyroid  gland  was 
completely  transformed,  (on  post-mortem  examina- 
tion). The  coloring  matter  was  almost  entirely 
absent;  the  vesicles  were  empty;  the  thyroid  cells, 


Pig.  35. — Sister  of  M.  A. — Myxedema. 

more  or  less  raised  towards  the  interior  of  the 
cavity,  did  not  fill  it,  and  there  was  no  cellular 
proliferation,  so  that  the  thyroid  tissue  appeared 
like  a  fine  network  between  the  meshes  of  the  con- 
nective tissue,  which  were  closer  than  usual.  There 
was  in  this  case  an  arrest  of  the  colloid  secretion, 
a  state  of  athyroidism."  Gamier  attributes  these 
lesions  to  the  bronchopneumonia  rather  than  to  the 
whooping-cough,  but  we  may  remark  that  whoop- 
ing-cough is  almost  constantly  complicated  by 
bronchopneumonia,  and  it  certainly  was  so  in  the 
case  of  our  little  patient.  One  is  not  then  astonished 
at  the  slight  progress  made  during  the  second  year, 

69 


and  it  is  worthy  of  note  that  whooping-cough 
showed  itself  able  to  lower  the  secretory  activity, 
even  in  this  child,  apparently  destitute  of  an  active 
thyroid  gland.  I  believe  that  however  degenerate 
it  may  be,  the  thyroid  gland,  even  in  the  most  con- 
firmed cretinism,  never  loses  entirely  its  secretory 
power,  as  the  complete  absence  of  thyroid  secretion 
from  the  blood  causes  death  in  a  short  time. 

In  the  course  of  the  second  year  the  parents  be- 
came much  alarmed  at  the  appearance  of  a  defect 
in  speech,  which  they  attributed  to  the  treatment. 
I  have  seen  several  similar  cases  in  analogous  cir- 
cumstances. The  child  had  great  difficulty  in  articu- 
lation, the  first  syllable  being  specially  hard  to  utter, 
so  that  she  panted,  gasped,  and  twisted  herself 
about.  Soon,  however,  this  disturbance  ceased 
spontaneously.  During  the  third  year  the  patient 
gained  21/2  inches  in  height. 

The  progress  in  the  fourth  year  was  also  unsatis- 
factory, the  treatment  being  irregularly  followed 
and  even  interrupted  for  some  months.  There  was, 
however,  a  gain  of  IV2  inches.  After  a  serious 
admonition  the  parents  became  more  attentive,  and 
in  the  course  of  the  fifth  year  the  child's  growth 
showed  a  distinct  improvement,  the  increase  in 
height  amounting  to  Zx/z  inches.  The  fourth  photo- 
graph (Fig.  2d)  shows  the  patient  as  she  appeared 
after  five  completed  years  of  thyroid  treatment. 
During  that  period  she  had  gained  15%  inches  in 
height,  her  lower  limbs  were  straight  and  well 
formed,  and  the  most  trained  eye  could  no  longer 
detect  the  slightest  indication  of  thyroid  defect. 

This  case  confirms  the  ideas  which  wa  have  long 
expressed  on  the  etiological  unity  of  several  morbid 
states  which  have  been  attributed  to  very  diverse 
causes.  Such  conditions  as  infantile  obesity, 
rickets,  the  slender  type  of  infantilism,  anangio- 
plasia,  chondrodystrophy,  myxedema,  the  arrested 
growth  in  congenital  syphilis,  the  arrest  and  delay 
of  growth  associated  with  alcoholism,  tobacco 
poisoning,  malaria,  and  tuberculosis,  are  all  due  in 
their  last  analysis  to  the  same  cause — a  lesion  of 
the  thyroid  gland.  Syphilis,  tuberculosis,  alco- 
holism, chronic  malnutrition,  and  consanguineous 
marriages  alike  deal  their  first  blow  at  the  thyroid 
gland  and  alter  its  secretion  in  various  directions. 
Does  not  the  perfect  recovery  from  the  rachitic 
changes  in  our  little  patient  show  us  that  this  con- 
dition is  due  to  an  alteration  in  the  thyroid  gland? 
Thyroid  extract  is   essentially  a  specific  and  can 

70 


benefit  only  the  lesions  which  come  within  its  sphere 
of  influence. 

The  different  morbid  influences  which  we  have 
just  enumerated  do  not  all  affect  the  thyroid  secre- 
tion in  the  same  manner.  This  secretion  is  very 
complex  in  its  composition,  containing  nucleins 
associated  with  phosphorus,  iodine  (Baumann), 
arsenic  (A.  Gautier),  and  even  bromine.  The 
thyroid  gland  is  liable  to  injury  from  several  direc- 
tions, and  from  this  results  the  great  variety  of 
trophic  disorders  which  are  the  echo  of  its  im- 
pairment. 

To  return  to  the  patient,  I  may  state  that  she 
continued  to  grow  till  21  years  of  age,  when  she 
measured  4  feet  9  inches  in  height.  Her  appear- 
ance at  the  age  of  24  is  shown  in  Fig.  23. 

Her  mother's  portrait  is  shown  in  Fig.  24,  her 
hair  is  silvery  white,  but  she  now  finds  herself 
healthier  than  fourteen  years  ago.  Since  the  meno- 
pause, the  thyroid  secretion,  which  during  her  re- 
productive life  was  devoted  to  the  inhibition  of 
menstruation  is  now  fully  available  for  the  general 
nutrition  of  the  body.  She  still  suffers,  however, 
from  breathlessness  and  rheumatic  pains,  and  when 
these  symptoms  become  troublesome  she  takes  thy- 
roidin  for  a  time  with  beneficial  effect. 

Let  us  now  take  an  example  of  mild  myxedema 
occurring  in  a  descendant  of  a  patient  presenting 
a  more  severe  type  of  myxedema. 

The  patient  shown  in  Fig.  25  was  the  daughter  of 
the  singing  master  whose  case  I  have  previously  de- 
scribed. The  woman  was  40  years  of  age.  At  all  times 
her  menstruation  had  been  profuse  and  exhausting  and 
she  suffered  much  from  migraine  and  dullness  in  the 
head,  while  her  hair  had  come  out  freely.  When 
closely  examined  her  face  presented  a  slight  degree  of 
swelling,  she  was  tired,  worn  out,  somnolent,  with  an 
urgent  desire  to  sleep.  At  the  time  she  complained  of 
sciatic  pains  in  the  left  leg.  Her  hands  were  large, 
cold,  bluish  red  in  color  and  were  covered  with  chil- 
blains in  winter.  Under  very  small  doses  of  thyroidin 
the  swelling  of  the  face  disappeared,  and  the  other 
symptoms  ceased,  including  the  shooting  pains  in  the 
left  sciatic.  This  case  forms  a  good  example  of  mild 
myxedema. 

Finally,  let  me  give  an  example  where  the  study 
of  the  collateral  relations  of  the  patient  has  been 
of  great  value. 

The  venerable  ecclesiastic  shown  in  Figs.  26  and  27 
suffered  from  well-marked  myxedema.  He  was  the 
priest  of  a  parish  in  the  neighborhood  of  Antwerp,  and 
having  visited  his  church,  which  was  of  archeological 
interest,  I  heard  him  preach.     He  stood  by  the  steps  of 

71 


the  altar  painfully  supporting  himself  with  both  hands 
on  the  communion  rail.  His  speech  was  so  defective 
that  I  could  not  understand  a  word  of  his  discourse. 
Then  he  mounted  the  steps  of  the  altar,  very  slowly, 
and  with  great  difficulty,  leaning  on  the  shoulder  of 
the  server.  There  was  no  doubt  as  to  the  diagnosis, 
he  was  suffering  from  well-marked  myxedema.  I  had 
the  satisfaction  of  quickly  restoring  him  to  health,  as 
may  be  seen  in  the  photograph.  This  patient,  as  you 
may  imagine,  had  been  previously  treated  in  various 
ways  in  the  course  of  a  disease  which  had  lasted  ten 
years.  He  was  much  troubled  by  great  thickening 
of  the  nasal  mucous  membrane,  for  which  he  consulted 
a  specialist,  who  nimbly  removed  a  portion  of  his  tur- 
binals,  at  the  price  of  an  alarming  hemorrhage. 
Myxedematous  patients  are  very  .hemophilic.  The 
operation  had  no  beneficial  result  for  the  patient. 

I  inquired  into  the  state  of  health  of  his  brothers 
and  sisters.  One  of  the  latter  lived  with  him,  she  was 
very  thin  and  had  a  pronounced  nasal  voice  with 
marked  hypertrophy  of  the  mucous  membrane  of  the 
nose.  This  was  in  her  the  only  symptom  of  thyroid 
defect.  Another  sister  was  married  and  presented  the 
appearance  shown  in  Fig.  28.  She  was  as  myxedema- 
tous as  her  brother  the  abbe.  Under  treatment  sne 
quickly  and  completely  recovered  her  health.  (Fig.  29.) 
But  this  was  not  all. 

The  abbe  had  a  brother  aged  54,  who  for  ten  years 
had  suffered  from  an  obscure  condition  characterized 
by  weakness,  anemia,  and  progressive  exhaustion 
(Fig.  30).  Along  with  the  loss  of  strength  his  vision 
had  gradually  failed  which  had  been  attributed  by 
well-known  specialists  to  white  atrophy  of  the  optic 
nerves.  Three  years  before,  on  his  return  from  an  ex- 
hausting journey,  he  suffered  severely  from  headache, 
then  suddenly  collapsed  and  became  unconscious  with 
complete  loss  of  motion  and  sensation.  This  state  of 
coma  lasted  three  days  and  on  recovery  he  remembered 
nothing  that  had  taken  place,  but  presented  no  loss 
of  functional  power.  He  continued  to  suffer  from 
weakness  and  exhaustion  and  his  eyesight  became 
steadily  worse,  so  that  when  I  saw  him  two  years  later 
he  was  almost  blind.  White  atrophy  of  the  optic 
nerves  has  been  recorded  several  times  in  the  course  of 
myxedema,  but  I  believe  that  this  is  purely  a  coinci- 
dence, and  that  there  is  no  causal  relation  between 
these  two  affections.  If  the  alteration  of  the  optic 
nerves  was  caused  by  the  specific  myxedematous  infil- 
tration, vision  would  return  under  the  influence  of 
thyroid  treatment,  as  we  have  seen  that  the  most  pro- 
nounced changes  of  the  nervous  system  due  to  this 
cause  are  capable  of  complete  restoration.  The  attack 
of  coma  which  the  patient  had  presented  had  placed 
his  medical  attendants  in  a  serious  difficulty.  As  there 
was  no  history  of  syphilis,  the  diagnosis  appeared  to 
lie  between  a  tumor,  hemorrhage,  and  embolism  of  the 
brain,  serous  apoplexy  being  excluded  by  the  absence 
of  albuminuria.  I  confess,  if  I  had  not  previously 
seen  the  abbe  and  his  sister,  I  would  not  have  suspected 
thyroid  weakness  in  this  case,  but  once  my  attention 
was  directed  to  this  possibility  it  was  easy  to  confirm 
the  diagnosis.  The  low  temperature,  the  yellowish  pal- 
lor and  slight  swelling  of  the  face,  the  fine  and  scanty 

72 


beard,  the  breathlessness,  and  extreme  weakness  all 
pointed  to  this  conclusion.  Even  the  attack  of  coma, 
hitherto  so  difficult  to  explain,  fitted  in  with  this 
opinion  in  a  very  simple  manner.  As  the  result  of  an 
harassing  journey  there  was  produced  an  abnormal  ex- 
haustion of  the  resources  of  the  thyroid  gland  in  a 
patient  in  whom  they  were  already  very  restricted. 
This  had  caused  a  severe  and  sudden  infiltration  of 
the  nervous  centers,  producing  an  attack  of  coma.  The 
immobility  secured  by  the  unconscious  condition  of  the 
patient  permitted  the  recovery  of  the  secretory  activity 
of  the  gland,  and  the  consequent  absorption  of  the  in- 
filtration, so  that  the  coma  passed  off  without  leaving 
any  paralysis  or  loss  of  function.  On  being  submitted 
to  thyroid  treatment,  this  man  regained  strength, 
color  and  self-confidence,  his  appearance  being  shown 
in  Fig.  31.  The  anemia  completely  disappeared,  but 
his  eyesight  did  not  improve  nor  could  it  be  expected 
to  do  so. 

A  last  example  showing  the  utility  of  an  inquiry  into 
the  family  history  is  the  case  of  M.  A.,  whose  photo- 
graph is  shown  in  Figs.  32  to  34.  This  is  the  most 
severe  case  of  myxedema  which  I  have  yet  met  with, 
and  also  that  which  I  have  most  closely  studied  and 
the  treatment  of  which  I  followed  from  day  to  day. 
When  I  first  saw  him,  the  patient  was  63  years  of  age. 
As  you  see  by  his  photograph,  he  was  much  infiltrated 
and  weighed  221  lb.,  although  he  ate  very  little,  having 
a  distaste  for  all  food,  especially  meat.  He  suffered 
much  from  breathlessness  and  was  incapable  of  the 
slightest  exertion.  Three  years  previously  he  had  had 
an  attack  of  epistaxis,  which  lasted  five  days  and 
threatened  to  prove  fatal,  when  the  bleeding  was  ar- 
rested by  an  injection  of  antidiphtheritic  serum.  Soon 
after  this  he  became  suddenly  comatose  for  a  period 
of  eight  hours.  As  he  had  long  been  known  to  suffer 
from  albuminuria,  and  had  been  treated  for  Bright's 
disease,  the  coma  and  epistaxis  were  naturally  attrib- 
uted to  the  renal  affection  and  regarded  as  signs  of 
uremia,  while  the  dyspnea,  intellectual  dullness,  head- 
aches, vertigo,  and  noises  in  the  ears  were  believed  to 
be  due  to  the  same  cause.  This  interpretation  must 
be  admitted  to  be  both  scientific  and  logical.  He  also 
suffered  from  nocturnal  incontinence  of  urine  which 
caused  him  great  distress.  He  rapidly  improved  under 
treatment,  his  appearance  after  two  months  being 
shown  in  Fig.  33.  At  this  stage  he  was  still 
weak  and  his  features  were  somewhat  haggard,  but 
the  fierce  expression  they  had  assumed  was  quite  mis- 
leading as  the  man  was  amiability  itself.  His  appear- 
ance after  fourteen  months'  treatment  is  shown  in 
Fig.  34.  He  has  become  a  little  stouter,  but  is 
in  complete  possession  of  all  his  faculties  and  his  face 
well  reflects  his  character  as  he  shows  extraordinary 
energy  in  the  management  of  his  affairs.  His  recovery 
was  absolutely  complete.  Some  idea  of  the  extent  of 
the  myxedematous  infiltration  may  be  obtained  by  a 
study  of  the  loss  of  weight  presented  by  this  patient. 
His  original  weight  was  221  lb.,  which  was  reduced 
in  the  course  of  two  months'  treatment  to  163  lb.  He 
thus  lost  48  lb.,  or  about  23  per  cent,  of  his  total  weight 
in  sixty  days,  being  at  the  average  rate  of  nearly  13 
ounces  a  day. 

73 


I  naturally  inquired  into  the  family  history  and 
found  that  about  ten  years  previously  the  patient's 
sister  had  died  in  a  state  of  coma  following  great 
fatigue  on  the  occasion  of  a  removal.  She  had 
formerly  had  an  attack  of  coma  and  had  for  some 
years  presented  albuminuria  and  been  treated  for 
Bright's  disease.  A  photograph  of  this  sister  is 
reproduced  in  Fig.  35.  You  will  observe  that  it 
has  been  carefully  retouched  in  order  to  supply 
the  absence  of  the  eyebrows  and  that  the  photog- 
rapher has  unsuccessfully  endeavored  to  reduce 
the  swelling  of  the  face  and  neck.  It  is  certain 
that  this  woman  suffered  from  myxedema  and  that 
the  apparent  Bright's  disease,  including  the  fatal 
attack  of  coma  was  due  to  myxedematous  infiltra- 
tion. Suitable  treatment  might  have  saved  her 
as  it  saved  her  brother. 

I  need  not  further  multiply  examples,  but  may 
sum  up  by  saying : 

When  you  encounter  the  association  of  one  or 
more  of  the  following  symptoms:  Trophic  changes 
in  hair,  eyebrows,  eyelashes,  teeth,  or  gums;  an 
habitual  chilliness,  biliary  disturbances  with  lith- 
iasis,  dyspnea  with  asthmatic  attacks;  menorrha- 
gia,  recurring  abortion,  hemophilia;  melancholia, 
depression,  weariness  of  life,  migraine,  vertigo, 
sudden  loss  of  consciousness,  noises  in  the  ears; 
somnolence,  rheumatoid  changes  in  the  muscles,  liga- 
ments, or  aponeuroses;  nocturnal  incontinence  of 
urine,  pollakiuria,  loss  of  appetite  and  obstinate 
constipation — think  of  a  possible  deficiency  of  the 
thyroid  secretion. 

Treatment. — I  will  conclude  with  some  practical 
indications  as  to  treatment.  The  theory  of  thy- 
roid defect  which  I  have  submitted  to  you  is  based 
on  the  undoubted  existence  of  an  infiltration,  the 
amount  of  which  varies  with  the  degree  of  defici- 
ency, but  which  is  always  present.  This  theory 
agrees  with  all  the  known  facts  and  is  strongly  sup- 
ported by  the  complete  restoration  of  the  body  as 
the  result  of  treatment.  There  is  no  destruction 
of  even  the  most  delicate  tissues,  since  all  of  them 
are  capable  of  resuming  their  functions  after  the 
administration  of  thyroidin.  This  theory  also  as- 
sists us  in  judging  the  progress  of  the  patient  and 
explains  the  various  incidents  which  may  be  pro- 
duced in  the  course  of  treatment.  Thus,  the  too 
rapid  absorption  of  the  infiltration  from  the  muscu- 
lar, nervous,  connective,  or  osseous  tissue  causes 

74 


painful  phenomena  exactly  similar  to,  but  more 
acute  than,  those  experienced  during  the  primary 
distention.  These  pains  are  easily  explained  by  the 
too  sudden  shrinking  of  the  walls  of  the  cells,  and 
perhaps  also  by  the  increased  oxidation  of  their  con- 
tents. Too  intensive  a  treatment  produces  violent 
headaches,  neuralgia,  anginiform  cardiac  symptoms 
which  are  apt  to  alarm  both  the  patient  and  the 
doctor.  Very  acute  rheumatoid  pains  also  develop 
in  the  muscles,  tendons,  and  joints,  especially  affect- 
ing the  anterior  muscles  of  the  leg,  the  extensor 
tendons  of  the  foot,  and  the  joints  of  the  toes.  I 
have  already  spoken  of  the  rise  in  temperature 
which  occurs  in  the  course  of  too  rapid  treatment. 

In  the  treatment  of  myxedema,  whether  mild  or 
severe,  let  us  have  the  courage  to  be  patient  and 
proceed  slowly,  as  it  is  unnecessary  to  cause  the 
absorption  of  more  than  3V2  to  5  ounces  of  infil- 
tration per  day. 

In  adults  a  dose  of  5  grains  of  thyroidin,  cor- 
responding to  an  English  tabloid  of  thyroid  ex- 
tract, is  quite  sufficient,  and  even  this  small  dose 
often  provokes  disagreeable  symptoms  in  connec- 
tion with  the  heart,  muscles,  and  joints.  Absorp- 
tion of  infiltration  should  be  controlled  by  daily 
weighing  of  the  patient.  It  is  found  that  children 
tolerate  thyroidin  better  than  adults. 

This  fundamental  treatment  should  be  assisted 
by  the  observation  of  certain  dietetic  rules.  Wine, 
beer,  alcohol  in  every  form,  and  also  tobacco,  should 
be  prohibited,  because  these  toxic  agents  diminish 
the  activity  of  the  thyroid  gland,  and  it  is  impor- 
tant to  spare  that  of  the  patient,  however  much  de- 
generated it  may  be. 

Complete  rest  in  bed  is  also  useful  during  the 
first  period  of  treatment,  because  when  in  bed  the 
thyroid  secretion  of  the  patient  is  not  expended  in 
useless  muscular  action.  Certain  forms  of  mild 
thyroid  defect  derive  benefit  from  the  adminis- 
tration of  small  doses  of  arsenic,  iodine,  or  bromine, 
because  these  substances  form  part  of  the  thyroid 
secretion.  Arsenic  is  of  value  in  the  forms  asso- 
ciated with  migraine,  while  a  combination  of  iodine 
and  bromine  benefits  the  cases  of  incontinence  of 
urine.  A  few  doses  of  an  active  purgative  may  be 
required  to  clear  the  viscera  when  loaded  after 
long-continued  constipation. 

I  need  hardly  say  that  I  absolutely  forbid  all 
cold  bathing,  but  hot  baths  on  the  contrary  are 
both  useful  and  pleasant  to  the  patient. 

75 


When  the  infiltration  has  been  absorbed,  that  is 
to  say,  when  the  patient  no  longer  loses  weight,  one 
must  endeavor  to  fix  the  dose  of  thyroidin  neces- 
sary to  maintain  him  in  health.  This  varies  from 
1  to  6  tabloids  a  week,  the  amount  being  slightly 
increased  in  winter  and  decreased  in  summer. 
When  once  the  patient  is  cured  one  should  not  be 
alarmed  to  see  him  increase  slightly  in  weight,  as 
with  the  better  assimilation  an  increase  of  stout- 
ness  is  to  be  expected. 

Finally,  it  may  happen  that  a  case  of  myxedema 
comes  under  observation  so  late  that  treatment 
seems  hopeless,  the  patient  having  sunk  into  a  state 
of  complete  coma,  and  death  seems  imminent.  I 
recently  saw  a  woman  in  whom  at  times  false  respi- 
ratory movements  occurred,  giving  the  impression 
of  Cheyne-Stokes  breathing  in  a  dying  person.  For 
several  days  two  nurses  took  turns  at  her  bedside 
in  order  to  support  her  chin.  A  metal  tube  was  in- 
serted between  her  teeth  and  connected  with  a 
supply  of  ogygen,  and  at  the  same  time  thyroidin 
was  administered  by  hypodermic  injection.  The 
symptoms  rapidly  improved,  the  periods  of  sus- 
pended respiration  became  less  frequent,  the  som- 
nolence disappeared,  and  the  temperature  rose  con- 
siderably— an  evident  sign  of  the  oxidation  of  the 
infiltration.  I  consider  this  patient  was  saved  by 
the  hypodermic  injections  of  thyroidin. 

In  a  case  of  prolonged  coma  one  would  be  justi- 
fied in  performing  lumbar  puncture  for  the  relief 
of  the  nervous  centers. 

I  have  now  sketched  the  leading  features  of  thy- 
roid defect  in  its  various  degrees.  I  have  not  been 
able  even  to  enter  on  a  number  of  interesting  points, 
but  I  have  said  enough  to  enable  you  to  observe 
around  you  facts  which  you  have  perhaps  hitherto 
not  suspected.  It  is  for  you  to  complete  these 
notions,  and  in  order  to  do  so  it  suffices  to  think  of 
them.  Trousseau  has  well  said  that  the  life  of  a 
physician  should  be  a  long  meditation. 

Just  as  we  search  all  our  patients  for  tubercu- 
losis, syphilis,  alcoholism,  a  day  will  come  when 
a  systematic  examination  will  also  be  made  to  ascer- 
tain their  thyroid  powers  and  defects.  The  ques- 
tion of  the  internal  secretions  is  coming  more  and 
more  to  the  foreground.  Innumerable  possibilities 
may  arise  from  it.  I  must  now  conclude  and  thank 
you  for  the  attention  and  time  you  have  so  liberally 
given   me. 

76 


REFERENCES. 

1.  Hypothyroidie  benigne  chronique  by  E.  Hertoghe, 
Bull.  Acad,  de  Med.  de  Belgique,  1899. 

2.  Bull,  de  l'Acad.  royale  de  Medecine  de  Belgique. 
Series  iii,  Vol.  XX,  No.  5,  p.  330. 

3.  On  experimental  congestion  of  the  liver  see  A. 
Ver  Eecke,  in  "Lesions  du  foie  et  des  reins  chez  les 
animaux  ethyroides."  Bull,  de  l'Acad.  royale  de  Med. 
de  Belgique,  October,  1897,  pp.  666,  686,  698,  and  704. 

4.  Hertoghe;  Myxoedeme  franc  et  fruste  de  l'enfance 
Nouvelle  Iconographie  de  la  Salpetriere.  Vol.  XIII, 
1900,  p.  411. 

5.  La  glande  thyroide  dans  les  maladies  infectieuses. 
By  Dr.  Marcel  Gamier,  Paris.  Georges  Carre  and  C. 
Naud,  1899,  p.  76. 


77 


INTRATRACHEAL  INSUFFLATION. 

By  BENJAMIN  MERRILL  RICKETTS,  M.D., 

CINCINNATI,    O, 

As  early  as  the  middle  of  the  sixteenth  century 
Vesalius  I.  recognized  the  possibility  of  aerating 
the  blood,  after  the  chest  had  been  opened,  by 
passing  a  continuous  current  of  air  through  the 
lungs;  while  in  1667  Hook  read  before  the  Royal 
Society  a  paper  entitled,  "An  Account  of  an  Ex- 
periment Made  by  Mr.  Hook  by  Preserving  Animals 
Alive  by  Blowing  Through  Their  Lungs  with 
Bellows." 

In  his  experiment,  Hook,  having  laid  open  the 
entire  thorax  of  a  dog  and  removed  the  pericardium, 
sustained  the  animal's  life,  first  by  reciprocal  in- 
flation and  deflation  of  the  lungs,  in  imitation  of 
normal  respiration,  and  then  by  means  of  a  con- 
stant current  of  fresh  air  under  such  pressure  that 
all  respiratory  movements  of  the  lungs  themselves 
were  suspended.  Both  methods  were  successful  in 
continuing  animation  and  the  pulmonary  circulation. 

While  mechanical  respiration  remained  a  valu- 
able adjunct  of  laboratory  experiment  for  almost 
250  years,  its  failure  as  a  human  resuscitative 
measure  in  the  practice  of  such  surgeons  as  LeRoy 
of  France,  and  Monroe  and  Dalrymple  of  Eng- 
land, forced  the  scientist,  John  Erichson,  in  1845 
to  conclude  that,  "In  spite  of  all  the  improvement 
and  modifications  of  the  technique  and  the  methods 
of  inflation  by  bellows,  mechanical  respiration 
never  again  came  into  favor  and  was  speedily  for- 
gotten when  the  postural  methods  came  into  use." 

Marshall  Hall  was  especially  severe  in  his  con- 
demnation of  forced  mechanical  respiration  by 
means  of  bellows,  and  until  1887  the  postural  re- 
suscitative methods  of  Hall,  Sylvester,  Schafer, 
and  Howard  were  extensively  employed. 

On  July  23,  1887,  Dr.  George  Edward  Fell  of 
Buffalo,  N.  Y.,  after  all  the  postural  methods  of 
resuscitation  had  been  tried  and  failed,  by  means  of 
forced  respiration  saved  the  life  of  a  patient  who 
had  taken  twenty  grains  of  morphine  and  some 
chloral  hydrate,  even  after  the  pupils  had  dilated 

Copyright,  William  Wood  &  Company. 

78 


in  the  la*st  stage  of  asphyxia.  Within  about  three 
months  following,  Prof.  Dr.  Boehm  of  the  Allge- 
meines  Krankenhaus  in  Vienna  saved  the  life  of 
Dr.  Langer  by  the  same  method. 

Other  successful  cases  of  a  similar  character 
followed,  and  established  a  new  epoch  of  artificial 
respiration.  In  practice  Dr.  Fell  used  an  espe- 
cially devised  face  mask  and  a  trachectomy  tube, 
and  later  an  intubation  tube,  the  invention  of 
Dr.  O'Dwyer,  connected  to  a  single  bellows  and 
provided  with  a  coronet  piston  exit  valve,  by  the 
manipulation  of  which  inflation  and  deflation  of 
the  lungs  could  be  made  to  duplicate  normal  breath- 
ing. In  one  instance,  the  case  of  Dr.  Williams,  re- 
ciprocal respiration  was  continued  intermittently 
during  four  days,  with  recovery  of  the  patient,  and 
without  any  untoward  pulmonary  laryngeal  or  sys- 
temic  complications. 

It  was  through  the  incentive  given  to  artificial 
respiration  by  the  introduction  of  Fell's  method  of 
"forced  respiration,"  and  his  adaptation  of  ether- 
ization to  the  technique,  that  the  surgery  of  the 
thorax,  through  its  utilization  became  a  possibility. 
F.  W.  Parham  of  New  Orleans  was  the  first  to  suc- 
cessfully remove  a  sarcomatous  growth  from  the 
walls  of  the  thorax,  using  "forced  respiration  anes- 
thesia" by  the  Fell-O'Dwyer  method,  for  purposes 
of  the  narcosis  and  combating  pneumothorax.  The 
operation  was  performed  under  reciprocal  breath- 
ing, and  the  chest  walls  were  closed  with  the  lungs 
fully  inflated.  Complete  recovery  of  the  patient 
ensued. 

About  1896  the  French  surgeon,  Tuffier,  in  asso- 
ciation with  Hallion,  after  exhaustive  intrathoracic 
experimentation  under  continuous  insufflation,  con- 
cluded that,  "the  success  of  this  method  on  ani- 
mals justified  its  use  in  man."  In  1902  Matas 
turned  his  attention  to  a  solution  of  the  surgical 
problems  involved  in  pneumothorax. 

Kuhn  of  Cassel,  who  had  made  intubation  a 
specialty  since  1895,  in  1905  came  out  with  a  posi- 
tive differential  method  for  compensating  pneumo- 
thorax, based  on  insufflation  by  intubation.  He  at 
first  closed  the  mouth  tight,  but  in  1908  improved 
his  previous  technique  by  introducing  two  tubes 
in  one,  a  narrow  tube  for  inbound  compressed  air 
and  a  wider  one  for  the  exhaust.  After  many  ex- 
periments on  the  human  being,  Kuhn  found  it  ad- 
visable to  keep  the  tube  out  of  the  trachea,  and  to 
stop  it  just  below  the  larynx.    While  Kuhn  demon- 

79 


strated  the  pulmonary  application  of  anesthesia 
by  intubation  to  Czerny  of  Heidelberg,  Trendelen- 
burg of  Leipsic,  Angerer  of  Munich,  and  Lotsch  of 
Berlin  visiting  each  of  these  surgeons  personally, 
nevertheless  the  method  was  not  favorably  received 
for  use  in  intrathoracic  surgery  on  the  human 
subject. 

In  1908  Robinson  of  Boston  intubated  through 
the  mouth  to  the  bifurcation  of  the  trachea,  send- 
ing in  air  under  pressure  through  a  cannula,  and 
letting  the  exhaust  escape  by  way  of  the  remaining 
lumen  of  the  trachea.  Later  Robinson  investigated 
the  Volhard-Sollman  method  of  oxygen  insufflation, 
by  means  of  which,  during  animal  experimentation, 
life  could  be  sustained  without  distention  of  the 
lungs;  but  he  was  distracted  from  perfecting  this 
or  the  air-insufflation  technique  by  becoming  in- 
terested in  progressive  improvements  which  he 
made  in  both  the  Brauer  and  Sauerbruch  methods. 

Mikulicz,  however,  must  be  credited  with  the 
first  systematic  investigation  of  the  physiological 
problems  besetting  intrathoracic  surgery.  At  his 
suggestion  in  1903  Sauerbruch  began  a  series  of 
experimental  researches,  and  in  1904  completed 
cabinets  for  intrathoracic  surgery,  using  respec- 
tively positive  or  negative  pressure. 

While  Sauerbruch  soon  discarded  his  hyperat- 
mospheric  apparatus  in  favor  of  his  negative- 
pressure  cabinet,  Brauer,  working  independently, 
developed  the  first  positive-pressure  chamber  to 
come  into  general  use.  The  apparatus  devised  by 
Karewski  resembled  closely  that  of  Bauer,  as  did 
also  the  initial  cabinets  of  Janeway  and  Green.  The 
devices  of  Tiegel  and  Brat-Schmieden  were  essen- 
tially of  the  emergency  or  laboratory  type,  although 
an  effort  was  made  to  adapt  them  to  the  more  ex- 
acting requirements  of  intrathoracic  surgery  on 
the  human  subject. 

What  Carrel  has  termed  the  "classical  type" 
(cabinet)  of  apparatus  has  found  its  apotheosis 
in  the  new  intrathoracic  surgical  pavilion  of  Willy 
Meyer  at  the  German  Hospital,  New  York,  in 
which  it  is  possible  to  operate  differential,  positive, 
or  negative  pressure  at  will. 

Until  the  present  popularization  of  intratracheal 
insufflation  by  the  Meltzer-Auer  technique,  what- 
ever real  progress  has  been  made  in  intrathoracic 
surgery  on  the  human  subject  must  be  credited 
to  the  "classical  style"   of  apparatus. 

•In   1908  Meltzer  saw    Sauerbruch    doing    intra- 

80 


thoracic  surgery,  and  later  witnessed  some  of  Willy 
Meyer's  operations  at  the  Rockefeller  Institute, 
and  seeing  both  pleural  cavities  wide  open  and  the 
animals  continuing  to  breathe,  but  not  trusting  the 
evidence  of  his  own  eyes  he  went  into  his  labora- 
tory to  verify  the  experiments.  A  year  later,  in 
association  with  Dr.  Auer,  he  published  an  article 
on  "Continuous  Respiration  without  Respiratory 
Movements."  After  Meltzer  had  perfected  the 
technique  of  intratracheal  insufflation  in  his  labo- 
ratory, Elsberg,  with  the  assistance  of  Yankauer, 
developed  an  apparatus  for  its  use  on  the  human 
subject,  and  personally  administered  anesthesia  by 
this  method  for  a  successful  thoracotomy  performed 
by  Dr.  Lilienthal  at  Mt.  Sinai  Hospital  in  1910. 

Meanwhile,  Morriston  Davies,  after  a  thorough 
investigation  of  all  the  intrathoracic  apparatus  and 
methods  in  vogue,  perfected  and  used  a  hyper- 
atmosheric  device,  combining  both  the  advantages 
of  the  cabinet  and  intratracheal  insufflation  tech- 
niques, and  to  Elsberg,  and  Peck  (New  York)  and 
Davies  (London)  belong  the  credit,  not  only  of 
adapting  intratracheal  insufflation  to  the  require- 
ments of  intrathoracic  surgery,  but  also  of  demon- 
strating its  value  as  a  technique  of  narcosis  in  the 
surgery  of  the  head  and  neck. 

While  the  "classical  type"  of  the  cabinet  and 
intratracheal  style  of  apparatus  are  in  apparent 
competition  for  supremacy,  still  each  has  its  possi- 
bilities and  its  limitations,  and  further  clinical  ex- 
perience alone  will  determine  their  respective  utility 
in  certain  definite  intrathoracic  surgical  procedures. 

Physiological  Considerations. — Progress  in  intra- 
thoracic surgery  has  depended  absolutely  on  the 
mechanical  control  of  pneumothorax  during  the 
operative  procedure.  This  mechanical  control  has 
varied  in  different  methods,  from  that  of  Hook,  now 
represented  by  the  Meltzer-Auer  technique,  in  which 
the  lungs  for  certain  periods  have  been  so  dis- 
tended by  a  constant  current  of  air  as  to  preclude 
more  or  less  any  respiratory  movements,  to  that  of 
Volhard-Sollman,  in  which  the  lungs  have  been 
allowed  to  collapse,  while  a  current  of  oxygen  sus- 
tained  life. 

However,  for  all  practical  purposes,  reciprocal 
breathing,  under  manometrically  controlled  posi- 
tive, negative,  or  differental  pressure,  has  proven 
the  only  safe  method  of  compensating  pneumothorax 
during  intrathoracic  operations  upon  the  human 
subject. 

81 


Any  consideration  of  pneumothorax  involves  an 
understanding  of  some  elementary  facts  of  the 
respiratory  mechanism.  Respiration  is  made  pos- 
sible in  the  thorax  of  the  human  subjects  by  a 
partial  vacuum  existing  in  the  pleural  space  after 
the  contraction  of  the  lungs  during  expiration. 
This  vacuum  is  represented  by  a  varying  negative 
pressure  of  from  4  to  10  mm.  of  mercury.  Conse- 
quently thoracotomy  requires  either  positive-pres- 
sure insufflation,  with  or  without  respiratory  move- 
ments, or  autorespiration  in  the  negative  or  differen- 
tial pressure  cabinet,  to  prevent  the  collapse  of  the 
lung  resulting  in  dyspnea,  displacement  of  the 
thoracic  viscera,  shock,  and  death. 

With  the  body  of  the  patient  within  the  cabinet 
in  which  the  air  has  been  rarefied  to  approximately 
the  negative  pressure  in  the  pleural  cavity  (4  to 
10  mm.)  and  the  head  of  the  patient  is  outside 
the  chamber,  permitting  the  respiring  of  normal 
pressure  atmosphere,  Sauerbruch,  by  varying  the 
negative  pressure  as  required,  has  been  able  to 
conduct  intrathoracic  operations  with  almost  the 
same  confidence  as  in  abdominal  surgery.  In  the 
Meyer  cabinet  differential  pressure  allows  the  sur- 
geon to  use  positive,  negative,  or  combinations  of 
both  pressures  as  needed.  The  great  distinction 
between  the  cabinet  control  of  pneumothorax  and 
intratracheal  insufflation  is  that  in  the  former 
autorespiration  is  depended  on  to  conserve  life, 
and  already  overtaxed  and  weakened  nerve  centers 
are  called  upon  to  formulate  respiratory  impulses, 
while  during  intratracheal  insufflation  these  centers 
can  be  made  to  remain  passive,  thereby  adding  a 
determining  factor  between  success  and  failure. 
Moreover,  in  some  operative  procedures  those 
muscles  which  participate  in  respiration  are  ren- 
dered inactive,  thereby  making  the  use  of  intra- 
tracheal insufflation  all  the  more  imperative.  This 
demand  is  accentuated  whenever  during  the  course 
of  any  intrathoracic  procedure  dislocation  of  the 
posterior  lobes  of  the  lungs  inhibits  the  usual  respi- 
ratory movements. 

Respiratory  movements  are  not  only  concerned 
in  the  aeration  of  the  lungs,  but  also  contribute  a 
factor  essential  to  the  normal  maintenance  of  the 
pulmonary  circulation  and  of  considerable  impor- 
tance to  that  of  the  systemic.  Thus  the  pulmonary 
circulation  may  be  regarded  as  of  double  function, 
the  ventricular,  impelling  the  blood  onward  with 
rapid  pulsations  of  the  cardiac  rhythm,  while  the 

82 


lungs  contribute  the  slower  but  more  voluminous 
impulses   of  the  respiratory  cycle.     (Davies.) 

Hence  it  is  that  during  intracheal  insufflation 
Meltzer  has  found  it  inadvisable  to  use  a  pressure 
which  altogether  suspends  respiratory  movements, 
resulting  in  apnea  and  C02  asphyxia,  and  suggests 
that,  in  so  far  as  it  is  possible  or  necessary,  the 
lungs  be  periodically  deflated  five  or  six  times  to 
secure  not  only  a  more  satisfactory  diffusion  of 
the  air  and  anesthetic  in  the  smaller  bronchi  and 
alveoli,  but  also  to  eliminate  COa  accumulation,  and 
further  to  preserve  the  stimulus  of  respiratory 
movements  upon  the  pulmonary  and  systemic  circu- 
lations. In  cases  of  open  pneumothorax  in  which 
the  respiratory  mechanism  is  not  paralyzed,  spon- 
taneous respirations  offer  the  required  aid  to  con- 
tinuous intratracheal  insufflation. 

However,  it  is  always  advisable  to  arrange  for 
occasional  interruptions  of  the  continuous  insuffla- 
tion, especially  in  operations  in  which  the  thorax 
has  to  be  laid  wide  open  and  the  posterior  and 
inferior  portions  of  the  lungs  have  to  be  dislo- 
cated, in  which  condition  spontaneous  respirations 
are  of  no  avail.  The  occasional  deflation  of  the 
lungs  insures  the  continuance  and  efficiency  of  the 
pulmonary  ventilation  under  all  circumstances.  It 
is  essential,  however,  that  this  deflation  be  not 
allowed  to  result  in  a  complete  collapse  of  the  lung, 
for  reinflation  under  the  circumstances  may  leave 
portions  of  the  lung  atelectatio. 

Moreover,  such  deflation  is  valuable  as  a  diag- 
nostic factor  in  differentiating  healthy  from  patho- 
logical lung  tissue  by  the  change  of  color  and  the 
presence  or  absence  of  proper  distention.  Again 
partial  deflation  is  useful  in  left-sided  pneumo- 
thorax, particularly  in  suturing  the  wounds  of  the 
heart,  under  which  circumstances  hemorrhage  from 
the  heart  wound,  according  to  Friedrich,  diminishes 
in  proportion  as  the  lungs  are  allowed  to  collapse. 

The  partial  pneumothorax  thus  becomes  the  regu- 
lator of  the  hemorrhage  and  is  allowed  to  persist 
until  suture  of  the  heart  wound  has  been  com- 
pleted, after  which  the  pericardium  and  pleura  are 
closed  with  the  lungs  properly  reinflated. 

Extensive  laboratory  experiments,  which  have 
been  verified  by  post-operative  results  in  the  human 
subject,  prove  conclusively  that  so  far  as  respi- 
ratory complications  are  concerned  intratracheal 
insufflation  is  an  innocuous  procedure  even  in  the 
presence  of  the  lobar  pneumonia.    Also  it  has  been 

83 


found  in  practice  that  the  recurrent  air-stream 
through  the  trachea  precludes  the  possibility  of 
aspirating  vomited  material  or  hemorrhage  from 
the  pharynx. 

Physiologically,  the  intrinsic  value  of  intra- 
tracheal insufflation  is  exemplified  not  only  in  the 
original  work  of  Fell,  but  also  in  the  laboratory 
experiments  of  Shaklee  and  Githens  on  the  treat- 
ment of  strychnine  poisoning,  in  which,  although 
the  very  centers  of  respiration  were  paralyzed,  in- 
tratracheal insufflation  reached  the  climax  of  its 
usefulness  as  a  measure  of  resuscitation  and  the 
conservation  of  life. 

Meltzer  has  also  found  that  anesthesia  by  intra- 
tracheal insufflation  is  far  superior  in  many  re- 
spects to  the  usual  methods  of  administering  ether. 
The  anesthesia  is  much  safer,  far  more  readily  con- 
trolled ;  less  of  the  anesthetic  agent  is  used,  patients 
go  under  and  come  out  more  rapidly,  and  an  effi- 
cient method  of  artificial  respiration  is  immediately 
at  hand  to  take  care  of  untoward  complications. 

In  recent  studies  on  the  influence  of  intra- 
tracheal insufflation  on  blood  pressure  and  respi- 
ration, Meltzer  and  Githens  found  that  a  mano- 
metric  pressure  of  from  30  to  40  mm.  and  a  percent- 
age of  ether  just  sufficient  to  complete  anesthesia, 
from  50  to  75  per  cent,  were  innocuous,  but  that 
an  increase  of  pressure  and  the  percentage  of  ether 
for  any  appreciable  length  of  time  would  result  in 
an  undulating  fall  of  blood  pressure,  a  slowly  and 
diminished  excursion  of  respiratory  movements, 
with  final  cessation  of  breathing,  although  the 
heart  continued  to  beat. 

Resuscitation  was  possible  in  animals  within  20 
minutes  by  the  insufflation  of  pure  air.  From  the 
experiments  it  appeared  that  an  overdose  of  ether 
first  paralyzed  the  functions  of  the  medulla  and 
then  much  later  the  functions  of  the  heart.  Hence 
the  caution  in  administering  intratracheal  insuffla- 
tion to  reduce  the  ethery  percentage  in  ratio  to  the 
shallowness  and  diminished  rate  of  respiration. 

Untoward  respiratory  and  associated  cardiac 
complications  may  also  result  from  operative  man- 
ipulation of  the  vagi  and  their  branches,  and  the 
resulting  false  apnea  may  be  controlled  by  the 
hypodermic  use  of  atropin. 

An  increase  of  pressure,  accomplished  either  by 
means  of  the  air  current  or  indirectly  by  momen- 
tary pressure  on  the  larynx,  is  valuable  not  only  in 
gauging  the  proper  distention  of  the  lung,  but  also 

84 


in  obviating  cyanosis  and  in  overcoming  the  re- 
sistance of  neurotic  individuals  to  the  anesthetic 
effects  of  the  ether.  All  investigators  have  found  it 
expedient  to  add  a  tank  of  oxygen  to  their  arma- 
mentarium for  intratracheal  insufflation.  Under 
certain  circumstances  a  persistent  cyanosis  will 
develop,  which  nothing  short  of  oxygenation  will 
control. 

While  Brauer  uses  the  Roth-Drager,  and  Davies 
the  Alcock  regulating  chloroform  apparatus  in  con- 
junction with  mechanical  respiration  for  purposes 
of  pulmonary  anesthesia,  ether  seems  to  be  a  far 
safer  agent  for  routine  narcosis  by  this  method. 

As  early  as  1827  Portal  produced  an  artificial 
pneumothorax  without  thoracotomy  by  the  injection 
of  sulphuretted  hydrogen  gas  into  the  thoracic  cav- 
ity to  place  the  lung  at  rest  when  affected  with  tu- 
berculosis. Holmgren  pursued  the  same  principle 
of  treatment  for  unilateral  pulmonary  tuberculosis 
even  in  cases  in  which  adhesions  between  the  vis- 
ceral and  parietal  pleurae  contraindicated  its  use. 
Hamman  of  Johns  Hopkins  is  now  utilizing  a  sim- 
ilar technique  with  nitrogen  gas.  In  the  presence 
of  adhesions,  the  pieliminary  injection  of  saline  so- 
lution to  collapse  the  lung  is  advisable  before  in- 
jecting the  gas  to  produce  the  therapeutic  pneumo- 
thorax. 

Perforation  of  the  thoracic  wall  does  not  always 
result  in  pneumothorax,  unless  the  opening  is  larger 
in  diameter  than  that  of  the  glottis,  or  is  valve-like 
in  character  as  in  oblique  puncture  of  wounds.  As 
a  rule,  pneumothorax  will  disappear  when  the  open- 
ing in  the  chest  wall  has  been  closed  by  the  adjacent 
integumentary  structures.  These  two  facts  have 
enabled  surgeons,  by  means  of  tubes  under  water 
and  the  use  of  rubber  tissue  dressings,  to  allow  for 
post-operative  drainage  of  the  thorax  without  arti- 
ficial control  of  pneumothorax. 

Technique  of  Intratracheal  Insufflation  Anes- 
thesia.— Apparatus  for  intratracheal  insufflation 
anesthesia  has  multiplied  rapidly  since  the  popu- 
larization of  the  method  by  Elsberg.  However,  all 
apparatus  is  similar  in  certain  essentials.  The 
source  of  air  current  may  be  provided  by  foot  bel- 
lows, hand-driven  or  electrically-driven  pumps,  and 
tanks  of  compressed  air.  The  air-current  may  pass 
directly  into  the  ether  container,  or  as  is  more  ad- 
visable, is  stored  in  a  low-pressure  tank  or  gas- 
ometer from  which  it  passes  into  a  Wolf  bottle,  to 
be  heated  and  moistened,  and  thence  by  regulating 

85 


valve,  either  directly  into,  or  only  partially  through 
the  ether  container,  thereby  providing  for  aera- 
tion pure  and  simple  or  insufflation  with  varying 
percentages  of  ether. 

Also  a  source  of  oxygenation  is  an  expedient  ad- 
junct. The  tube  from  the  apparatus  connects  with 
a  mercury  manometer  and  thence  to  the  intubation 
tube. 

Davies,  adopting  Kuhn's  idea  of  a  double  intuba- 
tion tube,  uses  a  manometer  to  gauge  the  inlet  and 
outlet  air  pressures. 

All  experimenters  have  concluded  that  for  the 
Meltzer-Auer  technique  a  silk-woven  catheter  30 
cm.  long  and  of  a  diameter  one-half  that  of  the  glot- 
tis, usually  from  22  to  26  of  the  French  scale,  serves 
as  the  best  intubation  tube.  It  should  have  an 
opening  similar  to  the  rectal  tube  at  the  tracheal 
end,  should  be  absolutely  smooth  and  semi-rigid  to 
prevent  it  from  being  expelled  by  coughing  or  from 
being  compressed  while  in  position. 

Its  introduction  is  best  accomplished  after  the 
preliminary  introduction  of  narcosis  by  ethyl 
chloride-ether  or  nitrous  oxide-oxygen-ether  anes- 
thesia. 

Intubation  is  greatly  facilitated  by  means  of 
either  the  Jackson  direct  laryngoscope,  Fischer's 
modification  of  Hayes's  instrument,  or  the  intro- 
ducer devised  by  Cotton.  After  the  patient  has 
been  deeply  narcotized  the  mouth  is  opened  wide 
and  so  held  by  a  gag.  The  head  is  well  brought 
forward  and  the  tongue  pulled  forward  by  an  as- 
sistant until  the  opening  of  the  larynx  is  brought 
into  view.  The  metal  guide  is  introduced  into  the 
opening  and  the  intubation  tube  is  gently  pushed 
onward  until  it  is  seen  to  pass  over  the  epiglottis 
into  the  larynx,  after  which  the  metal  guide  is 
withdrawn  and  the  tube  is  pushed  further  into  the 
trachea  until  it  meets  an  obstruction,  which  is 
either  the  wall  of  the  right  bronchus  or  the  bifurca- 
tion of  the  trachea.  It  is  then  withdrawn  an  inch 
and  is  anchored  in  position  to  special  mouth  gags 
provided  for  the  purpose. 

The  distance  from  the  incisors  to  the  bifurcation 
of  the  trachea  is  from  9  to  10  inches  in  the  infant, 
12  in  a  child,  and  about  17  inches  in  the  adult.  The 
glottis  in  the  adult  is  one-half  the  distance  between 
the  incisors  and  the  bifurcation  of  the  trachea,  and 
Elsberg  suggests  making  the  intubation  catheter 
accordingly  to  insure  greater  accuracy  in  adjusting 
its  location. 


86 


One-eighth  to  %  gr.  of  morphine  hypodermically 
ten  minutes  before  the  administration  of  ether  to 
reduce  the  irritability  of  the  larynx;  or  from  twenty 
minutes  to  half  an  hour  previously  when  prelim- 
inary anesthesia  by  ether  is  not  resorted  to.  The 
induction  of  narcosis  by  intratracheal  insufflation 
produces  spasmodic  coughing  while  the  patient  re- 
mains conscious. 

With  the  intubation  tube  introduced  to  the  cor- 
rect position,  air  may  be  heard  rushing  through  the 
catheter.  Spasm  of  the  larynx  may  now  occur  for 
a  few  moments,  but  is  of  no  consequence.  At  this 
juncture  the  tube  from  the  apparatus  is  connected 
to  the  catheter  with  the  pressure  gauge  of  the 
manometer  controlling  the  air  supply  at  20  mm. 
and  the  ether  percentage  at  50.  If  the  lungs  are 
not  kept  properly  distended  by  a  pressure  of  from 
10  to  20  mm.  Hg,  the  intratracheal  tube  is  either 
out  of  position  in  the  right  bronchus  or  is  too 
small  and  is  allowing  too  much  air  to  escape  by 
way  of  the  trachea.  In  the  first  instance  the  tube 
must  be  retracted  and  in  the  second  either  a  larger 
sized  tube  must  be  introduced  or  else  slight  com- 
pression of  the  trachea  around  the  tube  at  the  jugu- 
lum  must  be  intermittently  utilized.  Too  large  a 
tube  causes  CO,  accumulation  and  cyanosis. 

Complete  muscular  relaxation  is  usually  obtained 
with  from  50  to  75  per  cent,  of  ether,  and  during 
the  course  of  narcosis  the  breathing  is  quiet,  res- 
pirations are  reduced  by  one-third,  the  face  re- 
mains pink,  while  the  veins  of  the  forehead  become 
prominent;  the  pulse  usually  remains  full,  bound- 
ing, and  regular,  the  pupils  do  not  dilate,  and  fre- 
quently the  corneal  reflex  is  active,  so  much  so  that 
the  condition  of  the  patient  is  rather  one  of  anal- 
gesia than  anesthesia.  Reaction  from  the  anes- 
thesia is  so  rapid  that  care  must  be  exercised  to 
keep  up  etherization  throughout  the  entire  opera- 
tion. The  depth  of  narcosis  is  controlled  by  in- 
creasing the  air  pressure  and  the  percentage  of 
ether  while  at  the  same  time  avoiding  a  condition 
of  apnea,  which  supervenens  at  pressures  of  from 
30  to  40  mm.  Cyanosis  and  the  accumulation  of 
CO,  during  the  operative  procedure  are  controlled 
by  periodic  deflation  and  occasional  oxygenation 
with  air.  Pure  oxygen  is  dangerous  on  account  of 
its  toxicity  when  its  tension  becomes  too  great,  and 
it  is  too  freely  absorbed  by  the  circulation. 

At  the  close  of  anesthesia,  ether  is  turned  off,  and 
pure  air,  or  a  combination  of  air  and  oxygen,  is  in- 

87 


sufflated  under  slightly  increased  pressure  to  blow 
out  the  ether  from  the  trachea  and  alveoli.  Pa- 
tients come  out  from  under  the  influence  of  pul- 
monary anesthesia  by  this  method  almost  as  soon 
as  the  insufflation  is  discontinued  and  the  tracheal 
tube  removed.  Apnea  is  present  for  a  few  moments 
after  the  removal  of  the  intubation  tube,  but  regu- 
lar breathing  is  then  rapidly  re-established.  Post- 
anesthetic vomiting,  headache,  dyspnea,  and  cardiac 
complications  are  of  rare  occurence.  Postoperative 
pneumonia,  interstitial  emphysema  and  pleural  ef- 
fusions have  followed  intrathoracic  operations  done 
under  both  cabinet  and  intratracheal  insufflation 
methods  and  the  determining  etiological  factor  in 
the  complication  has  not  been  readily  determined. 
However,  caution  must  be  directed  to  a  technical 
mishap  which  may  occur,  and  that  is  an  accidental 
injection  of  fluid  ether  into  the  lungs.  Fischer 
quotes  a  case  in  his  own  experience  in  which  death 
resulted  from  this  contretemps  and  the  mishap  has 
occurred  in  laboratory  experiments.  Only  appara- 
tus should  be  used  which  mechanically  precludes 
the  possibility  of  such  an  occurrence. 

Again,  post-operatively,  it  may  become  necessary 
to  resume  insufflation  without  anesthesia  to  control 
shock,  to  aid  flagging  respiration  and  circulation, 
and  to  prevent  serious  effusions.  Under  such  cir- 
cumstances the  success  of  Fell  in  saving  life  under 
the  most  disheartening  conditions  must  be  remem- 
bered, and  the  method  pursued  to  its  limits. 

Aside  from  its  value  purely  as  a  resuscitative 
measure  in  asphyxia,  drowning,  poisoning  from 
drugs  and  anesthetics,  the  convulsive  stage  of 
rabies  and  tetanus,  impaired  respiratory  function 
in  certain  diseases,  it  must  also  be  remembered  that 
intratracheal  insufflation  as  a  method  of  anesthesia 
is  a  very  desirable  adjunct  to  the  surgery  of  the 
head  and  neck,  and  especially  for  operations  on  the 
spine  when  the  patient  must  be  placed  flat  on  the 
stomach  during  the  course  of  operative  procedure. 

While  etherization  in  association  with  intracheal 
insufflation  appears  to  be  the  safest  form  of  anes- 
thesia for  intrathoracic  operations,  Boothby,  after 
using  the  nitrous  oxide-oxygen-ether  technique, 
has  been  favorably  impressed  with  the  latter 
method,  and  Willy  Meyer  also  suggests  that  the 
innocuousness  of  nitrous  oxide  may  play  an  impor- 
tant role  in  conserving  patients  under  thoracotomy 
the  additional  shock  of  a  poisonous  anesthetic 
agent. 


88 


FOUR  CLINICAL  LECTURES. 
(Brief  Abstracts) 

HELD  AT  THE  NEW  YORK  POLYCLINIC  MEDICAL  SCHOOL 
AND  HOSPITAL  DURING  THE  WEEK  OF  THE  MEET- 
ING OF  THE  INTERNATIONAL  SURGICAL 

CONGRESS. 

I— FRACTURES   AND   BURNS. 

By  JOHN  A.   WYETH,  M.D. 

Dr.  Wyeth,  as  President  of  the  Faculty  and  Senior 
burgeon  of  the  New  York  Polyclinic  Medical  School 
and  Hospital,  after  welcoming  the  visiting  physi- 
cians and  surgeons,  spoke  briefly  on  "Fractures  and 
Burns,"  presenting  illustrative  cases  of  each.  Dr. 
Wyeth  said  in  part: 

I  shall  speak  this  morning  of  factures  of  a  single 
bone,  the  patella.  As  you  know,  fractures  of  the 
patella  are  caused,  as  a  rule,  by  violent  contrac- 
tions of  the  quadriceps  extensor  muscle  while  the 
leg  is  in  extreme  flexion.  The  bone  may  be  broken 
by  a  direct  blow  or  by  a  fall  on  the  knee.  A  blow 
and  muscular  action  may  combine  to  break  it. 

The  line  of  fracture  is  usually  transverse,  or 
nearly  so,  just  below  the  middle  of  the  bone.  The 
break  may  occur,  however,  above  or  below  this 
plane.  Occasionally  the  bone  is  split  longitudinally 
by  direct  violence,  or  it  may  be  comminuted.  Frac- 
ture of  the  patella  is  rarely  incomplete,  the  sepa- 
ration of  the  fragments  varying  from  the  smallest 
fraction  of  an  inch  to  as  much  as  two  or  more 
inches,  and  being  wider  at  the  inner  than  the  outer 
border.  This  lesion  occurs,  in  the  majority  of  in- 
stances, between  the  ages  of  twenty  and  forty,  and 
is  more  common  in  males  than  in  females. 

Because  of  the  superficial  location  of  the  lesion 
the  diagnosis  is  easily  made,  the  depression  between 
the  separated  fragments  serving  as  a  guide.  Should 
the  separation  be  very  slight,  lateral  motion  of  one 
fragment  upon  the  other  will  elicit  crepitus. 

In  the  treatment  of  this  condition  I  have  lately 
used  a  very  simple,  satisfactory,  and  painless 
method  of  holding  the  fragments  in  continuous 
apposition.  After  the  transverse  incision,  which 
exposes  both  broken  surfaces,  the  clot  is  washed 
out  with  hot  sterile  salt  solution,  and  the  frazzled 


Copyright,  William  Wood  &  Company. 

89 


periosteal  edges  are  sutured  together  with  fine  linen, 
thus  approximating  the  fragments.  The  skin  in- 
cision is  then  sutured  with  chromicized  catgut. 

On  a  two  and  a  half  inch,  half-curved  Hagedorn 
needle,  a  very  strong  linen  thread,  twelve  inches 
long  (No.  4)  is  carried  from  side  to  side,  deep  into 
the  substance  of  the  ligamentum  patella?,  just  at  its 
insertion  into  the  lower  rim  of  this  bone.  A  like 
thread  is  inserted  well  into  the  substance  of  the 
quadriceps  extensor  tendon  at  the  upper  margin  of 
the  upper  fragment.  A  light  gauze  dressing  is 
placed  over  the  line  of  incision,  and  over  this  the 
apposing  ends  of  the  two  linen  loops  on  each  side, 
above  and  below,  are  tied  tight  enough  to  hold  the 
fragments  in  close  and  continuous  apposition,  and 
without  the  possibility  of  overriding. 

A  dry  gauze  dressing  covers  the  field  of  oper- 
ation, and  a  plaster-of-Paris  cast  is  applied,  hold- 
ing the  knee  immobilized  for  eight  weeks.  At  the 
expiration  of  this  time  the  holding  sutures  are  re- 
moved and  the  fragments  are  held  securely  in  appo- 
sition, while  the  knee  is  bent  to  not  more  than 
20  degrees.  The  cast  is  reapplied  and  worn  for  four 
weeks  longer. 

The  limb  is  now  put  to  use,  with  the  necessary 
precaution  to  prevent  severe  strain  in  overflexion 
for  at  least  six  months. 

I  have  employed  this  method  in  the  cases  pre- 
sented, with  satisfactory  results. 

I  wish  also  to  present  a  case  of  an  extensive  burn 
of  the  face,  neck,  chest,  and  right  arm.  This 
patient  was  brought  to  the  hospital  in  the  ambu- 
lance last  night,  in  a  state  of  shock,  after  having 
been  rescued  from  a  burning  building. 

In  connection  with  this  case  it  may  not  be  amiss 
to  recall  to  your  minds  a  few  points  concerning 
burns  and  scalds,  which,  as  you  know,  may  vary  in 
degree  from  the  mildest  form  which  produces  a 
simple  inflammation  of  the  epidermis,  to  the  most 
severe  form,  which  destroys  all  the  tissues  or  organs 
or  a  part,  and  which  may  result  in  the  death  of  the 
individual.  The  gravity  of  the  prognosis  is  usually 
proportionate  to  the  extent  of  the  surface  of  the 
integument  destroyed,  rather  than  to  the  depth  of 
the  destructive  process. 

Burns  of  the  head  and  face,  such  as  the  patient 
presented,  are  the  most  dangerous;  those  of  the 
extremities  the  least  grave.  Recovery  rarely  fol- 
lows destruction  of  one-third  of  the  cutaneous  sur- 
face.    Death  may  result  from  shock,  from  ulcer  of 

90 


the  duodenum,  or  from  exhaustion  following  pro- 
longed suppuration  and  septic  absorption. 

When  a  severe  burn  or  scald  is  encountered  the 
immediate  indication  is  relief  of  pain  by  the  hypo- 
dermatic administration  of  morphia,  or  by  some 
form  of  opium  given  by  rectum  or  stomach.  The 
most  convenient  local  remedy  is  a  saturated  solu- 
tion of  baking  soda  in  water,  with  submersion  of 
the  burned  surface,  if  possible,  or  a  mixture  of 
bicarbonate  of  soda  and  cornstarch,  one  teaspoonf  ul 
of  each  to  a  quart  of  water.  The  dressing  should 
be  kept  wet  with  the  solution,  which  is  applied 
freely  to  the  burned  area.  After  five  or  six  hours 
the  free  application  of  the  following  mixture,  made 
into  an  emulsion,  will  be  found  beneficial: 

Ichthyol    3ss 

Cotton-seed  or  olive  oil O.ss 

Limewater   O.ss 

This  should  be  continuously  applied  for  the  first 
three  to  five  days  during  the  stage  of  acute  in- 
flammation. 

In  order  to  bring  about  rapid  repair  of  the  skin 
the  following  ingredients,  mixed  thoroughly,  may 
be  used: 

Ichthyol 3j 

Diachylon  ointment, 

White  vaseline aa  §ii j 

If  these  remedies  are  not  convenient,  the  follow- 
ing may  be  substituted  with  equal  benefit: 

Lead  plaster, 

Liquid  albolene, 

Lanolin, 

Vaseline aa  §j 

These  are  melted  together,  and,  when  cooling,  40 
minims  of  ichthyol  added. 

Either  of  these  ointments  should  be  applied 
thickly  on  the  soft,  linty  side  of  canton  flannel,  on 
surgeon's  lint,  or  on  several  layers  of  sterile  gauze. 
The  application  should  be  repeated  daily  at  first, 
after  opening  all  blebs.  In  opening  the  blebs  care 
should  be  taken  not  to  remove  the  epidermis  of  the 
bleb,  as  this  may  become  revitalized,  thus  greatly 
accelerating  the  healing  process.  In  changing  the 
dressing  it  is  important  not  to  disturb  new  granu- 
lations, but  simply  to  wipe  over  them.  When  heal- 
ing is  well  under  way  the  dressing  need  be  changed 
only  every  second  or  third  day. 

In  the  treatment  of  the  depression  or  shock  which 
often  follows  severe  burns,  stimulation  with  whiskey 

91 


or  brandy,  by  enema  or  by  mouth,  is  indicated, 
as  well  as  the  hypodermic  injection  of  morphine. 
Physiological  salt  solution,  introduced  by  the  colon, 
or  injected  into  the  areolar  tissue,  is  of  great  value 
when  the  burn  is  extensive  and  the  shock  profound. 
It  should  always  be  remembered  that  opium  and 
alcohol  should  be  given  sufficiently  cautiously  to 
avoid  too  profound  narcosis  with  the  former,  and 
with  the  latter  increase  in  the  fever  reaction  which 
follows  when  the  patient  rallies  from  the  shock. 

In  an  emergency,  when  the  remedies  mentioned 
may  not  be  obtained,  a  coating  of  ordinary  white 
lead,  as  mixed  for  use  in  painting  dwellings,  is  an 
efficient  protection  when  poured  over  the  burn. 
Flour  sprinkled  over  until  all  the  excoriated  surface 
is  well  hidden  is  a  method  of  treatment  which  is 
applicable  in  almost  any  emergency.  Rubber  tis- 
sue, or  oil-silk,  sterilized  and  laid  over  the  raw 
surface,  with  cotton  batting  applied  over  it,  but 
never  directly  on  the  burned  surface,  is  equally 
efficient.  Lint,  or  a  soft  cloth,  dipped  in  a  2  per 
cent,  carbolized  oil,  may  be  employed  directly  on 
the  burn. 

No  pressure  should  be  exercised  in  holding  the 
dressings  in  place.  When  the  back  and  posterior 
aspects  of  the  extremities  are  chiefly  involved,  the 
prone  position  is  of  necessity  maintained. 


92 


FOUR   CLINICAL  LECTURES. 

II— OPERATIONS     FOR     INGUINAL    HERNIA 

UNDER  LOCAL  ANESTHESIA. 

By  JOHN  A.   BODINE,  M.D. 

Dr.  Bodine  presented  a  case  of  ordinary  right- 
sided  inguinal  hernia,  upon  which  he  operated 
under  local  anesthesia,  employing  a  solution  of 
novocain,  1-500.    Dr.  Bodine  said  in  part: 

In  operating  under  local  anesthesia  the  nervous 
apprehension  of  the  patient  may  be  quieted  to  a 
great  degree  by  a  calmative  demeanor  upon  the 
part  of  the  surgeon  and  his  assistants.  This  is 
also  influenced  by  the  patient's  position  upon  the 
table.  A  position  of  comfort  and  relaxation  should 
be  maintained.  If  the  arms  are  crossed  above  the 
head  the  patient  will  be  "fidgety"  throughout  the 
operation. 

In  the  effort  to  avoid  bleeding  points  it  is  of 
great  importance  that  the  lower  end  of  the  incision 
should  not  extend  beyond  the  lateral  end  of  the 
suprapubic  skin  fold.  It  may  be  started  as  high 
as  one  desires.  This  incision  may  be  deepened  to 
the  operative  field  without  encountering  a  vessel 
large  enough  to  demand  a  ligature,  whereas,  if  the 
incision  be  extended  an  inch  lower,  a  large  number 
of  ligatures  will  be  required.  Not  only  does  the 
catgut  thus  employed,  when  softened  by  the  tissues, 
invite  sepsis,  but,  in  cocaine  work,  it  means  a  num- 
ber of  acute  stabbing  pains  whenever  a  blood  vessel 
is  cut  or  tied.  The  incision  so  placed  gives  ample 
room  by  downward  traction  of  the  mobile  skin,  and 
nearly  always  permits  the  completion  of  the  oper- 
ation without  the  use  of  a  ligature. 

The  line  of  incision  is  infiltrated  with  the  novo- 
cain or  other  anesthetic  solution  throughout  its 
extent.  This  is  accomplished  by  introducing  the 
needle  just  under  the  superficial  epithelium.  The 
anesthesia  thus  induced  will  permit  the  incision  to 
be  painlessly  deepened  to  the  aponeurosis  of  the 
external  oblique.  Upon  splitting  and  reflecting  the 
aponeurosis,  the  iliohypogastric  nerve  is  anesthet- 
ized by  injecting  a  little  of  the  solution  into  the 
sheath  of  the  nerve  as  high  up  as  possible. 

The  ilio-inguinal  nerve  is  also  sought,  but  if  it  is 
not  found  the  hernial  coverings  should  be  infiltrated 
in  a  straight  line  over  the  neck  of  the  sac,  and  the 

93 


incision  deepened  until  this  structure  is  reached. 
If  omentum  is  excised  it  is  generally  gently  with- 
drawn, ligated  and  amputated  without  additonal  in- 
jection, and,  in  my  experience,  without  pain.  If, 
however,  only  the  iliohypogastric  nerve  has  been 
found  some  infiltration  will  be  needed  into  the  con- 
joined tendon.  The  cord  is  lifted  from  its  position 
and  the  operation  concluded  according  to  the  Bassini 
method. 

Two  suggestions  are  offered  which  have  proved 
of  worth  to  me:  First,  if  a  strip  of  gauze  is  used 
to  hold  up  the  cord  it  may,  during  the  necessary 
manipulation,  roll  the  cord  on  its  long  axis,  and 
exposure  to  air  may  cause  agglutination  in  this 
position  of  torsion.  A  wetted  strand  of  catgut  as  a 
retractor  will  obviate  this  danger.  Second,  the  deep 
suture  should  include  but  one-half  the  thickness  of 
the  conjoined  tendon,  thus  avoiding  strangulation. 


1)4 


FOUR  CLINICAL  LECTURES. 
Ill— FRACTURES. 

By  ALEXANDER  LYLB,   M.D. 

Dr.  Lyle  presented  three  patients  whose  histories 
were  briefly  detailed,  in  part,  as  follows : 

Case  I. — This  patient,  a  man  forty-nine  years  of  age, 
while  working  in  the  well  of  an  elevator  was  crushed 
by  the  descending  car,  sustaining  injuries  to  the  pelvis. 
Upon  being  released  from  his  confined  position  he  com' 
plained  of  scarcely  any  pain,  and  it  was  not  until  he 
made  an  attempt  to  stand  that  the  pain  became  notice- 
able. 

Careful  examination  revealed  a  fracture  of  the 
pelvis,  the  exact  extent  of  which  could  not  be  de- 
termined by  palpation.  Examination  by  rectum  elicited 
no  evidence  of  injury  to  this  organ,  and  catheteriza- 
tion of  the  bladder  showed  no  blood  in  the  urine.  Shock 
was  not  marked.  The  patient  was  placed  in  bed  and  a 
very  tight  wide  muslin  binder  put  about  the  pelvis. 
The  following  day  an  x-ray  examination  was  made, 
which  revealed  a  very  marked  bilateral  fracture  of  the 
pelvis.  In  the  skiagraph  an  irregular  line  of  the  frac- 
ture could  be  seen,  starting  from  the  crest  of  the  ilium 
and  extending  down,  terminating  in  the  greater  sciatic 
notch.     There  were  no  wounds  in  the  skin. 

The  patient  was  observed  very  closely  after  being 
put  to  bed,  in  order  to  determine  the  presence  of  any 
internal  injuries,  but  the  abdominal  viscera  proved  to 
be  uninjured. 

The  treatment  of  this  case,  like  that  of  all  fractures 
of  the  pelvis,  has  been  very  simple.  Straps  of  ad- 
hesive plaster  were  brought  around  the  pelvis,  in  order 
to  immobilize  it,  and  this  was  reinforced  by  a  firm  mus- 
lin bandage.  The  patient's  convalescence  has  been  un- 
eventful. He  will  be  kept  quiet  in  bed  for  eight  weeks 
before  he  is  allowed  to  stand. 

In  all  cases  of  this  kind  it  is  well  to  bear  in 
mind  the  great  danger  of  rupture  of  the  urethra, 
of  the  bladder,  and  of  the  pelvic  vessels.  As  soon 
as  internal  injury  can  be  determined  operation 
should  be  resorted  to. 

Case  II. — The  next  patient,  a  woman  of  thirty-five 
years  of  age,  sustained  a  transverse  fracture  of  the 
surgical  neck  of  the  humerus,  as  shown  in  Fig.  1.  The 
head  of  the  humerus  may  be  seen  in  the  glenoid  fossa, 
while  the  broken  end  of  the  shaft  has  pierced  the 
pectoral  muscles  and  lies  immediately  beneath  the 
clavicle. 

After  several  attempts  to  reduce  this  fracture  and  to 
hold  it  in  position  by  mechanical  means  had  failed,  it 
was  determined  to  open  through  the  deltoid  and  replace 
the  fragments.  With  complete  ether  anesthesia,  the 
bone  was  exposed.     Upon  bringing  the  fragments  to- 

95 


Fig.    1. — Fracture   of   the   neck   of  the   humerus. 

gether  it  was  found  that  they  could  be  dove-tailed  into 
each  other  so  firmly  that  plating  or  wiring  was  unneces- 
sary. The  tissues  were  then  sutured,  a  small  pad  of 
cotton  placed  in  the  axilla,  and  a  firm  plaster-of-Paris 
spica  applied. 

The  patient's  condition  being  excellent,  the  dressing 
was  not  removed  for  four  weeks.  It  was  then  taken 
down  and  a  light  one  applied,  which  remained  for  two 
weeks  longer.  Following  removal  of  this,  massage  and 
passive  motion  were  used,  the  patient  now  having  al- 
most complete  use  of  her  arm.  Fig.  2  shows  the  condi- 
tion after  operation. 

Case  III. — The  third  patient  is  a  young  man  twenty- 
four  years  of  age,  who  sustained  a  fracture  of  the 
lower  third  of  the  right  femur,  as  shown  in  Fig.  3.  He 
is  a  truck  driver  by  occupation,  and  is  consequently 
very  muscular.  It  will  be  noticed  in  the  plate  that  the 
muscles  have  contracted  to  such  an  extent  that  the 
fragments  have  overlapped  fully  an  inch. 

Formerly  our  treatment  in  such  cases  consisted 


96 


Fig.  2. — Fracture  of  the  neck  of  the  humerus  after  reduction. 

in  the  application  of  Buck's  extension,  with  suffi- 
cient weights  attached  to  counteract  the  muscular 
force.  Much  of  this  traction  was  exerted  upon  or 
below  the  knee,  and  consequently  knee-joint  com- 
plications often  became  more  severe  than  the  frac- 
ture. We  now  have  a  very  decided  improvement  in 
the  line  of  traction  in  the  Steinmann  nail.  This  con- 
sists of  a  long  spike  of  steel  which  is  put  through 
the  lower  end  of  the  femur,  just  above  the  condyles, 
and  by  the  use  of  tongs  traction  is  exerted  upon 
this,  the  knee-joint  being  left  perfectly  free. 

Fig.  4  shows  the  femur  after  the  Steinmann  ap- 
paratus has  been  in  service  and  twelve  pounds  of 
weight  applied  over  the  pulley.  It  will  be  observed 
that  not  only  has  the  muscular  force  been  overcome, 
but  that  the  fragments  have  been  pulled  over  an 
inch  apart.  At  this  point  the  weights  were  reduced 
to  six  pounds,  and  a  plaster-of-Paris  roll  bandage 
applied  over  the  lower  two-thirds  of  the  femur,  in 
order  thoroughly  to  immobilize  the  fragments  that 
are  now  in  perfect  alignment. 

97 


A  B 

Pig.  3. — Fracture  of  the  femur  ;  A,  front  view  ;  B,  side  view. 


Fig. 


4. — Fracture  of  the  femur,  shown  in  Fig.   3,  after  treat- 
ment with  the   Steinmann  apparatus. 


98 


The  patient's  convalesence  was  normal  in  every 
respect  and  he  was  able  to  walk  out  of  the  hospital, 
without  the  assistance  of  even  a  cane,  at  the  end 
of  eight  weeks. 


99 


FOUR  CLINICAL  LECTURES. 
IV— CANCER. 

By  WILLIAM  SEAMAN  BAINBRIDGE,  M.D. 

Dr.  Bainbridge  presented  a  number  of  patients. 
In  some  instances  the  patients  had  been  operated 
upon  for  cancer  at  a  previous  time,  in  others 
operations  were  performed  on  this  occasion.  One 
particular  case  belonging  to  the  first  category,  sug- 
gested certain  practical  points  with  reference  to  the 
diagnosis  and  treatment  of  malignant  disease,  a 
partial  report  of  which  is  here  given : 

The  patient,  a  woman,  seventy-one  years  of  age,  pre- 
sented herself  at  the  hospital  in  March,  1914,  complain- 
ing of  "throat  trouble."  In  January,  according  to  the 
history,  another  physician  opened  the  left  tonsil  for 
"quinsy,"  the  tonsil  at  that  time  being  enlarged  and 
painful.  The  diagnosis  of  syphilis  had  been  made  by 
one  physician  consulted,  but  the  Wassermann  reaction 
was  negative,  as  was  likewise  the  history.  Before  I  saw 
her  for  the  first  time,  in  March,  a  small  piece  of  the 
tonsil  had  been  removed  for  pathological  examination, 
and  the  pathologist  had  reported  "inflammatory  tissue." 

When  the  patient  came  under  my  observation  the  ton- 
sil was  very  much  enlarged,  indurated,  and  the  sur- 
face ulcerated.  The  surrounding  tissue  was  edematous 
and  reddened.  The  patient  complained  of  great  pain, 
and  of  difficulty  in  swallowing.  Three  sections  were  re- 
moved from  the  ulcerated  portion,  and  these  were  given 
to  three  independent  pathologists  for  examination.  One 
sent  in  the  report,  "inflammatory  tissue";  the  other  two 
reported  "sarcoma."  The  latter  coincided  with  the 
clinical  diagnosis,  and,  inasmuch  as  the  mass  was 
growing  very  rapidly,  with  danger  of  death  from 
hemorrhage,  immediate  operation  was  advised. 

On  April  3,  at  the  Polvclinic  Hospital,  the  patient  was 
operated  upon  under  general  ether  anesthesia.  The 
external  carotid  artery,  including  the  ascending  pharyn- 
geal branch,  was  ligated,  and  the  mass  removed,  with  as 
thorough  dissection  as  circumstances  allowed. 

The  patient  recovered  from  the  operation,  and  ex- 
perienced great  relief  from  the  dysphagia  and  general 
suffering  caused  by  this  enormous  mass,  which  had  filled 
almost  the  entire  mouth.  To  have  left  this  mass,  involv- 
ing the  soft  palate,  and  interfering  with  respiration 
and  deglutition,  would  have  meant  early  death,  either 
from  hemorrhage  or  from  pressure  upon  the  trachea 
and  consequent  interference  with  breathing.  By  tying 
off  the  large  vessels  it  was  possible  to  remove  the  tumor, 
to  relieve  suffering  and  to  prolong  life. 

After  the  operation  pieces  of  the  tonsil  were  again 
sent  to  different  pathologists  for  a  verification,  if  pos- 
sible, of  the  clinical  diagnosis  of  malignancy.  Of  the 
four   pathologists   who   examined   these   independently, 

100 


three  reported  round-celled   sarcoma,  and  one,  inflam- 
matory tissue. 

A  case  of  this  kind  is  fraught  with  a  number  of 
valuable  lessons. 

In  the  first  place,  it  emphasizes  the  vital  im- 
portance of  making  a  careful  and  thorough  diag- 
nosis, even  in  apparently  simple  affections  such  as 
"sore  throat"  and  "quinsy."  Many  times,  in  the  daily 
routine  of  the  busy  practitioner  or  of  the  hospital 
or  dispensary  physician,  it  is  difficult  to  accord  to 
each  case  the  careful  diagnostic  consideration  which 
it  should  receive.  For  this  reason  the  conscientious 
and  capable  physician  or  surgeon  may  make  errors 
in  diagnosis  which  a  little  more  time,  care,  and 
thought  would  obviate. 

The  same  thing,  it  seems,  applies  to  the  patholo- 
gist. If,  armed  with  an  adequate  history  of  the 
case  and  with  the  clinician's  presumptive  diagnosis 
of  malignancy,  the  pathologist  is  content  to  examine 
one  or  two  slides  with  negative  results,  and  to 
render  a  negative  report,  he  is  very  apt  to  fall  into 
many  pitfalls  in  diagnosis.  Ordinarily,  a  few  slides 
will  reveal  the  true  diagnosis,  but  it  must  not  be 
forgotten  that  this  may  not  be  the  case.  Sometimes 
malignancy  is  established  only  after  the  examina- 
tion of  a  large  number  of  sections.  Numbers  of  in- 
stances of  this  kind  have  been  reported  by  myself 
and  others.  For  this  reason  a  negative  pathological 
diagnosis  should  not  be  accepted  in  the  light  of 
positive  clinical  evidence  of  malignancy.  The  case 
under  discussion   illustrates  this  point. 

In  this  connection  it  may  be  reiterated  that 
adequate  clinical  data  in  each  case  should  be 
given  to  the  pathologist.  It  is  fair  neither  to  the 
pathologist,  to  the  patient,  nor  to  the  surgeon  him- 
self, that  the  laboratory  worker  be  expected,  from 
the  sections  alone,  to  give  reliable  findings  in  all 
cases. 

In  the  second  place,  the  case  emphasizes  the  im- 
portance of  bearing  in  mind  the  question  of  the 
auto-infectivity  of  cancer.  It  cannot  be  positively 
stated,  but,  from  the  subsequent  history,  it  is 
quite  probable  that  the  first  operation,  that  of 
incising  the  tonsil  for  what  was  supposed  to  be 
"quinsy,"  or  acute  suppurative  tonsillitis,  stimu- 
lated malignant  growth  and  accounted  for  the 
rapid  extension  of  the  sarcoma.  It  is  likewise 
quite  fair  to  assume  that  this  operation  very  materi- 
ally affected  the  ultimate  outcome  of  the  case,  for, 
while  the  patient,  at  the  present  time,  is  fairly  com- 

101 


fortable,  can  breathe  and  swallow  with  ease,  and  is 
free  from  the  danger  of  immediate  death  from 
hemorrhage,  suspicious  induration  in  the  neck  sug- 
gests early  and  rapid  recurrence. 

This  patient's  history  recalls  another  case  which 
came  under  my  observation  in  this  institution  in 
1908.  Each  illustrates,  in  a  telling  manner,  the 
dangers  of  breaking  down  nature's  barriers  either 
for  the  purpose  of  taking  specimens  for  micro- 
scopic study  or  through  an  error  in  diagnosis.  In 
the  case  which  I  have  just  presented  to  you  the 
growth  was  first  cut  into  through  a  mistake  in  diag- 
nosis, and  afterward  for  the  purpose  of  taking  a 
specimen.  In  the  other  case  to  which  I  refer  the 
second  error  was  committed.  In  this  instance  a 
little  boy,  three  years  of  age,  developed  a  small 
tumor  in  front  of  the  ear- after  a  fall  which  caused 
a  bruise  in  this  region.  The  interne  in  the  dis- 
pensary of  the  hospital  to  which  the  mother  carried 
the  child  cut  into  this  small  lump  and  took  out  a 
section  for  pathological  examination,  telling  the 
mother  to  return  with  the  child  in  two  weeks.  The 
result  was  that  the  tumor  increased  enormously  in 
size  and  with  great  rapidity,  with  involvement  of 
the  lymphatics  of  the  neck  and  with  metastases  in 
the  liver,  spleen,  and  testes.  Within  about  nine 
months  from  the  time  the  child  received  the  fall 
the  condition  had  become  inoperable,  and  the  neo- 
plasms, which  proved  to  be  sarcoma,  irremovable. 
This  was  the  condition  when  I  first  saw  the  patient, 
consequently  no  operation  was  performed.  The 
child  died  early  in  December,  the  fall  having  oc- 
curred in  February. 

Such  cases,  one  in  a  woman  of  seventy-one  and 
the  other  in  a  child  of  three,  emphasize  the  im- 
portance of  keeping  nature's  barriers  intact,  in  all 
instances  where  there  is  a  doubtful  question  of  ma- 
lignancy. Instead  of  incising  the  unbroken  skin  or 
mucous  membrane,  the  entire  tumor  should  be  re- 
moved and  the  section  taken  afterward  for  purposes 
of  verification  of  diagnosis,  and  for  determining 
the  advisability  of  more  extensive  removal  of  tissue. 
If,  perchance,  nature's  barriers  have  already  been 
broken  down,  as  in  the  case  of  the  woman,  a  sec- 
tion may  generally  be  removed  without  increasing 
the  danger  of  extension.  Under  all  circumstances, 
when  the  clinical  diagnosis  of  maligancy  is  doubt- 
ful and  a  section  is  removed  for  microscopic  veri- 
fication or  reinforcement,  a  prompt  report  should 
be  insisted  upon,  in  order  that  immediate  operation 

102 


may  be  resorted  to  if  necessary.  Inasmuch  as  neg- 
ative pathological  reports  are  not  to  be  accepted  in 
the  face  of  positive  clinical  diagnosis,  it  is  often  ad- 
vantageous to  resort  to  frozen  sections  at  the  time 
of  operation  for  the  purpose  of  determining,  in  the 
light  of  the  pathological  findings,  the  extent  of 
operative  interference. 

In  closing  I  wish  to  reiterate  once  more  the  im- 
perative duty  of  every  surgeon  who  operates  for 
cancer  to  utilize  all  the  diagnostic  aids  now  at  our 
command  before  pronouncing  a  condition  malignant 
or  non-malignant.  Sins  of  commission  may  be  just 
as  disastrous  to  the  patient  as  sins  of  omission  in 
the  matter  of  operative  interference,  and  it  is  only 
by  refinements  of  diagnosis,  plus  the  careful  weigh- 
ing of  all  the  evidence  that  we  may  avoid  both 
pitfalls. 


103 


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